Nokea
The nurse is assessing a 4-month-old infant who has just received routine immunizations. The mother reports that the baby has been fussy and has a low-grade fever since the immunizations. What is the best response by the nurse?
- A. These are common side effects and should resolve within a few days
- B. Your baby may be having an allergic reaction to the immunizations
- C. You should bring your baby to the clinic immediately for evaluation
- D. You should give your baby aspirin to help with the fever
Correct Answer: A
Rationale: Fussiness and low-grade fever are common side effects of immunizations in infants and usually resolve on their own. It is important for the nurse to educate the mother about these expected reactions to help ease her concerns. Immediate evaluation or giving aspirin to an infant for fever is not necessary or safe, as aspirin can be harmful to infants.
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A 16-year-old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (Proventil) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky and her heart feels like it is 'beating a mile a minute.' Which information is most important for the nurse to obtain?
- A. When she last took the antihistamine.
- B. When her last asthma attack occurred.
- C. Duration of most asthma attacks.
- D. How often the MDI is used daily.
Correct Answer: D
Rationale: The most important information for the nurse to obtain in this scenario is how often the MDI is used daily. This is crucial to assess if the symptoms the student is experiencing, such as insomnia, shakiness, and tachycardia, could be related to overuse of the inhaler. Overuse of albuterol can lead to side effects like tremors, palpitations, and difficulty sleeping, so understanding the frequency of MDI use is key in determining a potential cause for the student's symptoms.
The heart rate for a 3-year-old with a congenital heart defect has steadily decreased over the last few hours, now it's 76 bpm, the previous reading 4 hours ago was 110 bpm. Which additional finding should be reported immediately to a healthcare provider?
- A. Oxygen saturation 94%.
- B. RR of 25 breaths/minute.
- C. Urine output 20 mL/hr.
- D. BP 70/40.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the nurse's priority action for a 2-year-old child with croup presenting with a barking cough and stridor?
- A. Administer a corticosteroid
- B. Obtain a throat culture
- C. Administer nebulized epinephrine
- D. Place the child in an upright position
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing?
- A. Separation anxiety.
- B. Associative play.
- C. Object prehension.
- D. Object permanence.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When should a mother introduce solid foods to her infant? The mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant. The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry
- B. Opens mouth when food comes her way
- C. Awakens once for nighttime feedings
- D. Gives up a bottle for a cup
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.