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The nurse is assessing a 6 month old infant. Which response requires further evaluation by the nurse?
- A. Has doubled birth weight.
- B. Turn head to locate sound.
- C. Plays peek-a-boo.
- D. Demonstrates startle reflex.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A toddler with a chronic illness that requires frequent hospitalization is likely to experience which psychosocial developmental challenge?
- A. Fixation with feelings of inadequacy
- B. Interference with the development of autonomy
- C. Distortion of differentiation of self from parent
- D. Delayed language, fine-motor, and self-care skills
Correct Answer: B
Rationale: Toddlers with chronic illnesses requiring frequent hospitalization may experience interference with the development of autonomy. This is because the need for constant medical care can restrict their independence and ability to explore and make choices, which are essential aspects of achieving autonomy according to Erikson's stages of psychosocial development.
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.
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.
A 2-year-old child is admitted with severe dehydration due to gastroenteritis. Which assessment finding indicates that the child's condition is improving?
- A. Decreased heart rate.
- B. Sunken fontanelle.
- C. Increased urine output.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A two-year-old child with heart failure is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
- A. Determine the pulse deficit.
- B. Administer the scheduled dose.
- C. Calculate the safe dose range.
- D. Review the serum digoxin level.
Correct Answer: B
Rationale: Administering the scheduled dose is appropriate in this scenario as the heart rate of 128 bpm falls within the acceptable range for a two-year-old child with heart failure. It indicates that the child may benefit from the therapeutic effects of digoxin. Monitoring the heart rate closely after administration is essential to ensure the medication's effectiveness and safety.