Nokea
The nurse is discussing growth and development with a group of parents. What should the nurse say about developmental milestones?
- A. Increase in body size.
- B. Age-specific tasks that most children can do at a certain time.
- C. The direction of growth.
- D. Refers to the age group of children.
Correct Answer: B
Rationale: The correct answer is B: "Age-specific tasks that most children can do at a certain time." Developmental milestones are specific tasks or abilities that most children can achieve at a certain age range. Choices A, C, and D are incorrect because developmental milestones are not just about increase in body size, the direction of growth, or the age group of children. They are more focused on the expected tasks and skills children can accomplish at particular ages.
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Which action should the nurse implement when taking an axillary temperature?
- A. Take the temperature through one layer of clothing
- B. Add a degree to the result when recording
- C. Place the tip of the thermometer under the arm in the center of the axilla
- D. Hold the child's arm away from the body while taking the temperature
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the appropriate placement of a tongue blade for assessment of the mouth and throat?
- A. On the lower jaw
- B. Side of the tongue
- C. Against the soft palate
- D. Center back area of the tongue
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the appropriate method for measuring the temperature of a 2-day-old neonate?
- A. Tympanic
- B. Oral
- C. Axillary
- D. Rectal
Correct Answer: C
Rationale: For a 2-day-old neonate, the most suitable method to measure temperature is the axillary method. This approach is considered safe and appropriate for neonates, minimizing the risk of injury. Tympanic temperature measurement may not be as accurate in neonates due to their small ear canals. Oral temperature measurement is not recommended for neonates as they may not be able to hold a thermometer properly in their mouths. Rectal temperature measurement is invasive and carries a higher risk of injury and should be avoided unless absolutely necessary.
In assessing sexual maturity levels, which tool would you expect to use?
- A. Denver II Developmental Screening
- B. Tanner staging
- C. Antibody testing
- D. Nursing process
Correct Answer: B
Rationale: The correct answer is B: Tanner staging. Tanner staging is a tool specifically used to assess sexual maturity in adolescents based on the development of secondary sexual characteristics. The Tanner scale ranges from stage 1 (prepubertal) to stage 5 (adult maturity). This tool helps healthcare providers evaluate the physical development and sexual maturation of individuals. Choice A, the Denver II Developmental Screening, is used to assess developmental milestones in children. Choice C, antibody testing, is a diagnostic tool used to detect the presence of specific antibodies in the blood. Choice D, the nursing process, is a systematic method that nurses use to deliver patient-centered care, involving assessment, diagnosis, planning, implementation, and evaluation.
The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)
- A. Lightly brush the palate with a cotton swab
- B. Perform the examination in front of a mirror
- C. Let the child examine someone else's mouth first
- D. All of the above
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.