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The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?
- A. Avoid smoke exposure.
- B. Inspect the infant's ears daily.
- C. Position prone after feeding.
- D. Breastfeed frequently.
Correct Answer: A
Rationale: Avoiding smoke exposure reduces the risk of otitis media recurrence, a known risk factor.
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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.
A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?
- A. The mother states the baby is irritable during feedings.
- B. The mother is a single parent and lives with her parents.
- C. The infant's formula has been changed twice.
- D. The diaper area shows severe skin breakdown.
Correct Answer: D
Rationale: Severe skin breakdown can cause discomfort, disrupting sleep, and requires immediate intervention to improve the infant's comfort.
The nurse is assessing a preschool-aged child who presents with flank pain, dysuria, and low-grade fever. To determine a possible urinary tract infection, which additional information should the nurse gather from the parent?
- A. Pale urine.
- B. Increased fluid intake.
- C. New onset bedwetting.
- D. Voiding every 4 hours.
Correct Answer: C
Rationale: New onset bedwetting in a preschool-aged child can indicate a urinary tract infection, as it may reflect irritation or loss of bladder control.
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.
A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant's skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)?
- A. Sweat-chloride test.
- B. Faecal-fat test.
- C. Pulmonary-function test.
- D. Potassium chloride test.
Correct Answer: A
Rationale: Salty-tasting skin is a hallmark of cystic fibrosis, and the sweat-chloride test is the standard diagnostic test.