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The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?
- A. Suggest placing the iron drops in the orange juice and then feeding the infant.
- B. Give the mother positive feedback about the way she administered the medication.
- C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
- D. Tell the mother to follow the iron drops with infant formula instead of orange juice.
Correct Answer: B
Rationale: Giving orange juice after iron drops enhances iron absorption due to vitamin C, so positive feedback is appropriate.
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A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?
- A. List of achievement timeline for developmental milestones.
- B. Reactions to any previous hospitalizations.
- C. A history of rubella, rubeola, or chicken pox.
- D. Mother's use of alcohol, drugs, or cigarettes during pregnancy.
Correct Answer: B
Rationale: Previous hospitalization reactions help anticipate and address fears, aiding in care planning.
The parents of a 14-month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to these parents?
- A. Ibuprofen should be used prophylactically to prevent febrile seizures.
- B. Provide the child with a sponge bath for temperatures over 100.6°F (38.1°C)
- C. Reassure the parents that febrile seizures decrease as the child grows older.
- D. Avoid excessive visual stimuli because it can precipitate seizure activity.
Correct Answer: C
Rationale: Most children outgrow febrile seizures by age 5, reducing parental concerns about lifelong seizures.
A newborn with a repaired gastroschisis is transferred to the paediatric unit after several days in the paediatric 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. Offer a pacifier for non-nutritive sucking.
- B. Use sterile technique during feedings.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Speak to the healthcare provider about instituting physical therapy.
Correct Answer: A
Rationale: Non-nutritive sucking via a pacifier promotes oral motor skill development, supporting normal feeding behaviors critical for growth.
The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appear slightly yellow. Additionally, urine in his diaper appears tea-colored. This child should receive follow-up assessment for what condition?
- A. Intussusception.
- B. Biliary atresia.
- C. Hirschsprung's disease.
- D. Huntington's disease.
Correct Answer: B
Rationale: Jaundice and tea-colored urine suggest biliary atresia, requiring urgent follow-up to prevent liver damage.
The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?
- A. Rebound tenderness in the left lower abdominal quadrant.
- B. Stool that consists of mucus and blood.
- C. Olive-size mass in the epigastric area.
- D. Frequent burping accompanied by poor feeding.
Correct Answer: C
Rationale: An olive-size mass in the epigastric area is characteristic of pyloric stenosis, associated with projectile vomiting.