Nokea
The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?
- A. Position prone after feeding.
- B. Breastfeed frequently.
- C. Avoid smoke exposure.
- D. Inspect the infant's ears daily.
Correct Answer: C
Rationale: Avoiding smoke exposure reduces eustachian tube irritation, lowering otitis media risk.
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The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
- A. Place a toy in the child's hands while listening to the breath sounds.
- B. Allow the child to use a stethoscope on a stuffed animal.
- C. Offer the child bubbles before the stethoscope is placed.
- D. Have the child blow a cotton ball and have the parent catch it.
Correct Answer: B
Rationale: Using a stethoscope on a stuffed animal engages the child, reducing fear and improving cooperation.
The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure. The infant's vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute. Which medication should the nurse hold and inform the health care provider?
- A. Enalapril
- B. Digoxin
- C. Furosemide
- D. Hydralazine
Correct Answer: B
Rationale: The infant's apical pulse of 88 beats/minute is below the normal range (100-160 beats/minute) for an eight-month-old, indicating a need to hold Digoxin and notify the provider.
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?
- A. The thyroxine level is low because the TSH level is high.
- B. High thyroxine levels normally occur in breastfeeding infants.
- C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
- D. The TSH is high because of the low production of T4 by the thyroid.
Correct Answer: D
Rationale: High TSH results from low T4 production, indicating congenital hypothyroidism.
A 9-week-old infant is scheduled for a cleft lip repair. What information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. Urine specific gravity is 1.011
- B. White blood cell count of 10,000/mm³
- C. Weight gain of 2 pounds (0.91 kg) since birth
- D. Red blood cell count of 2.3 x 10²/L
Correct Answer: D
Rationale: A low red blood cell count indicates anemia, a surgical risk requiring preoperative attention.
The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Recognizes most letters and numbers
- B. Uses 1-word sentences
- C. Speaks in simple sentences with four or more words
- D. Uses gestures with 1 to 2-word sentences .
Correct Answer: C
Rationale: Simple sentences with four or more words are expected for a 3-year-old's language development.