Nokea
The nurse is educating parents of a 2-month-old infant about immunizations. What immunizations against illness should their child receive?
- A. Pertussis (whooping cough)
- B. Influenza
- C. Diphtheria
- D. Tetanus
- E. Polio
Correct Answer: A,B,C,D,E
Rationale: At 2 months, infants receive their first DPT (diphtheria, tetanus, pertussis), polio, and influenza immunizations to protect against these illnesses.
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What will the nurse weighing the infant today expect her weight to be?
- A. At least 12 pounds
- B. At least 16 pounds
- C. At least 20 pounds
- D. At least 24 pounds
Correct Answer: B
Rationale: Birth weight is usually doubled by 6 months, so an infant with a birth weight of 8 pounds, 2 ounces should weigh at least 16 pounds.
What would the nurse expect a 4-month-old infant to be able to accomplish?
- A. Hold a cup.
- B. Stand with assistance.
- C. Lift head and shoulders.
- D. Sit with back straight.
Correct Answer: C
Rationale: Due to cephalocaudal development, a 4-month-old infant can lift their head and shoulders, mastering this skill before others listed.
What is the best action the nurse would advise the parent to implement?
- A. Use commercial diaper wipes to clean the area.
- B. Apply a protective ointment on the area.
- C. Change the infant's diaper less frequently.
- D. Keep the diaper area covered all of the time.
Correct Answer: B
Rationale: Applying a protective ointment on pink, irritated skin helps treat diaper rash effectively.
What is the most helpful measure the nurse can suggest to the mother?
- A. Sing songs to the infant in a soft voice.
- B. Place the infant in a well-lit room.
- C. Walk around and massage the infant's back.
- D. Rock the fussy infant slowly and gently.
Correct Answer: D
Rationale: Rocking the infant gently and slowly, while avoiding sudden movements, is an effective technique to soothe a colicky infant.
What finding should the nurse report to the physician immediately?
- A. Respiratory rate of 60 breaths/minute
- B. Pulse rate of 100 beats/minute
- C. Minimal verbalization
- D. Fussy behavior
Correct Answer: A
Rationale: A respiratory rate of 60 breaths/minute is above the normal range of 20 to 40 for a 1-year-old and indicates potential distress.