The nurse is teaching the mother of a 9-month-old infant about administering liquid iron preparation. Which information should be included in the teaching?
- A. Adequate dosage will turn the stools a tarry, black color.
- B. Give Vitamin D to enhance absorption.
- C. Allow the liquid iron to mix with saliva before swallowing.
- D. Give the liquid iron with meals.
Correct Answer: A
Rationale: The correct answer is A. Iron supplements can cause stools to turn black, which is a normal and harmless side effect. Iron is best absorbed on an empty stomach, although it can be given with food if gastrointestinal upset occurs. Vitamin C, not D, enhances iron absorption. Choice B is incorrect because Vitamin C enhances iron absorption, not Vitamin D. Choice C is incorrect as there is no need to mix liquid iron with saliva before swallowing. Choice D is incorrect because iron is best absorbed on an empty stomach.
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After teaching a group of nursing students about developmental milestones for children between the ages of 1 and 4 years, the instructor determines that the teaching was successful when the students identify which of the following as a gross motor developmental milestone that occurs between 2 to 3 years of age?
- A. Jumping in place
- B. Climbing
- C. Standing on one foot with help
- D. Riding a tricycle
Correct Answer: B
Rationale: Climbing is a gross motor milestone typically achieved between 2 to 3 years of age. It involves coordination and strength. Jumping in place is usually mastered around 2 years of age. Standing on one foot with help is a skill that emerges around 3 years. Riding a tricycle typically occurs closer to 3 years and involves coordination and balance, which are more refined skills compared to climbing at an earlier age.
The nurse is caring for a 2-year-old child in the postoperative period. Which pain assessment tool is most appropriate for assessing pain intensity in a 2-year-old?
- A. Poker chip tool
- B. Oucher Scale
- C. Faces Pain Rating Scale
- D. FLACC Behavioral Pain Assessment Scale
Correct Answer: D
Rationale: The FLACC Behavioral Pain Assessment Scale is the most suitable tool for assessing pain in 2-year-old children postoperatively. It assesses pain by evaluating facial expression, leg movement, activity, cry, and consolability, making it effective for non-verbal children. The Poker chip tool is not appropriate for this age group. The Oucher Scale and Faces Pain Rating Scale are more suitable for older children who can self-report pain levels.
When assessing a preschooler's chest, what should the nurse expect?
- A. Respiratory movements to be chiefly thoracic
- B. Anteroposterior diameter to be equal to the transverse diameter
- C. Retraction of the muscles between the ribs on respiratory movement
- D. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which?
- A. Lacking in protein
- B. Indicating they live in poverty
- C. Providing sufficient amino acids
- D. Needing enrichment with meat and milk
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The parents of an 8-month-old infant voice concern to the nurse that their infant is not developing motor skills as the infant should. What question would be appropriate for the nurse to ask in determining if their fears are warranted?
- A. Does the infant move a toy back and forth from one hand to the other?
- B. Is the infant able to drink from a cup by oneself?
- C. Is the infant able to hold a pencil and scribble on paper?
- D. Does the infant place toys into a box or container and take them out?
Correct Answer: A
Rationale: The correct answer is A. By 8 months, an infant should be able to transfer objects between hands, which is an important motor skill milestone. This action shows coordination and developing fine motor skills. Choices B, C, and D involve more advanced motor skills that are typically not expected at 8 months of age. Drinking from a cup, holding a pencil to scribble, and engaging in purposeful play with toys are skills that develop later in infancy.
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