Nokea
The nurse observes a mother administering ferrous sulfate (iron drops) to her 11-month-old child, followed by 2 ounces (60 mL) of orange juice. What should be the nurse's subsequent action?
- A. Advise the mother to follow the iron drops with infant formula instead of orange juice.
- B. Commend the mother on her method of administering the medication.
- C. Propose mixing the iron drops in the orange juice before feeding the infant.
- D. Direct the mother to refrain from feeding the infant for 30 minutes after giving the iron drops.
Correct Answer: B
Rationale: Orange juice's vitamin C enhances iron absorption, making the method appropriate.
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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 the client?
- A. Flex the knees.
- B. Raise the hips.
- C. Cross the arms and legs.
- D. Perform a log roll.
Correct Answer: D
Rationale: Log rolling maintains spinal alignment, protecting the surgical site during movement.
A newborn with a repaired gastroschisis is transferred to the pediatric unit after several days in the pediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Speak to the healthcare provider about instituting physical therapy.
- B. Offer a pacifier for non-nutritive sucking.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Use sterile technique during feedings.
Correct Answer: B
Rationale: Offering a pacifier for non-nutritive sucking promotes oral feeding skills and emotional stability, supporting normal growth and development in infants with gastroschisis repair.
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
- A. Apply lotion to hands and feet.
- B. Encourage the parents to rest when possible.
- C. Make a list of foods that the child likes.
- D. Place the child in a quiet environment.
Correct Answer: D
Rationale: Placing the child in a quiet environment reduces stimulation and promotes rest, addressing irritability, a primary symptom of Kawasaki disease.
A 7-year-old child has been admitted to the hospital with a diagnosis of acute rheumatic fever. When taking a health history from the child's mother, which recent illness is of most significance?
- A. Chickenpox.
- B. Mumps.
- C. Sore throat.
- D. Influenza.
Correct Answer: C
Rationale: A recent untreated strep throat can lead to acute rheumatic fever.
When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
- A. Monitor peripheral pulses and sensation in the right leg
- B. Cleanse pin sites as prescribed
- C. Check skin for redness and signs of tissue breakdown
- D. Reposition the child every 2 hours
Correct Answer: A
Rationale: Monitoring pulses and sensation is critical to detect vascular or nerve complications from traction.