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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. Plays 'peek-a-boo.'
- C. Demonstrates startle reflex.
- D. Turns head to locate sound.
Correct Answer: C
Rationale: The startle reflex typically disappears by 3-4 months; its presence at 6 months may indicate a developmental or neurological issue.
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The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving this client?
- A. Cross the arms and legs.
- B. Perform a log roll.
- C. Raise the hips.
- D. Flex the knees.
Correct Answer: B
Rationale: The log roll technique maintains spinal alignment, critical after surgical spinal instrumentation.
The nurse is providing teaching to a school-age child with left femoral osteomyelitis and the child's parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment?
- A. Administer topical antibiotic therapy daily.
- B. Provide passive range of motion exercises.
- C. Ensure no weight bearing on the affected extremity.
- D. Schedule ice pack applications to the infected area.
Correct Answer: C
Rationale: No weight bearing on the affected extremity prevents further damage during the initial treatment phase of osteomyelitis.
While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?
- A. Inspect the posterior oropharynx.
- B. Touch the tonsillar pillars to stimulate the gag reflex.
- C. Ask the child to speak to evaluate change in voice tone.
- D. Assess for teeth clenching or grinding.
Correct Answer: A
Rationale: Frequent swallowing may indicate postoperative bleeding, so inspecting the oropharynx is critical.
The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?
- A. Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process.
- B. Use a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage.
- C. Administer the injection into the middle of the lateral aspect of the thigh.
- D. Divide the gluteal area into quarters and give IM into the upper outer quadrant.
Correct Answer: C
Rationale: The lateral thigh is the recommended IM injection site for toddlers, minimizing nerve and vessel damage.
The nurse is caring for a toddler with autism spectrum disorder and failure to thrive. Which intervention should the nurse implement?
- A. Provide structured meal times.
- B. Offer food even if disinterested.
- C. Incorporate play during meals.
- D. Allow multiple food choices.
Correct Answer: A
Rationale: Structured meal times promote routine and reduce sensory overload, aiding feeding in children with autism spectrum disorder.