Nokea
The nurse judges that the mother has understood the teaching about care of an infant with colic when the nurse observes the mother doing which of the following?
- A. Holding the infant prone while feeding.
- B. Holding the infant in her lap to burp.
- C. Placing the infant prone after the feeding.
- D. Burping the infant during and after the feeding.
Correct Answer: D
Rationale: Burping during and after feeding reduces air swallowing, easing colic symptoms. Prone positioning during or after feeding increases aspiration risk, and lap burping is less effective.
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At the 2 week well-child visit a parent states, 'My baby seems to keep his head tilted to the right.' The nurse should further assess the:
- A. Fontanel.
- B. Cervical vertebrae.
- C. Trapezius muscle.
- D. Sternocleidomastoid muscle.
Correct Answer: D
Rationale: Torticollis is commonly caused by tightness or shortening of the sternocleidomastoid muscle, which should be assessed for asymmetry or tightness.
When teaching the child with scoliosis being treated with a Boston brace about exercises, the nurse explains that the exercises are performed primarily for which of the following purposes?
- A. To decrease back muscle spasms.
- B. To improve the brace's traction effect.
- C. To prevent spinal contractures.
- D. To strengthen the back and abdominal muscles.
Correct Answer: D
Rationale: Exercises for scoliosis in a Boston brace focus on strengthening back and abdominal muscles to support spinal alignment and improve posture.
The parent of a 9-month-old infant is concerned that the infant's front soft spot is still open. The nurse should tell the parent:
- A. I will measure your baby's head to see if it is a normal size.
- B. Your infant will need to be referred for more testing.
- C. You should contact your physician immediately.
- D. It is normal because this soft spot usually closes between 12 and 18 months.
Correct Answer: D
Rationale: The anterior fontanelle typically closes between 12-18 months, so this is normal.
A mother brings her 18-month-old to the clinic because the child 'eats ashes, crayons, and paper.' Which of the following information about the toddler should the nurse assess first?
- A. Evidence of eruption of large teeth.
- B. Amount of attention from the mother.
- C. Any changes in the home environment.
- D. Intake of a soft, low-roughage diet.
Correct Answer: C
Rationale: Changes in the home environment may contribute to pica, which requires immediate assessment.
Which of the following assessment findings should alert the nurse to suspect appendicitis in a male adolescent complaining of severe abdominal pain?
- A. Abdomen appears slightly rounded.
- B. Bowel sounds are heard twice in 2 minutes.
- C. All four abdominal quadrants reveal tympany.
- D. The client demonstrates a cremasteric reflex.
Correct Answer: B
Rationale: Decreased bowel sounds suggest appendicitis due to peritoneal irritation.