Nokea
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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An infant is born with anencephaly. Based on the knowledge of this diagnosis, what information does the nurse consider when interacting with the family?
- A. Many treatment options exist.
- B. Immediate surgery is necessary.
- C. The condition is incompatible with life.
- D. The child will have permanent disabilities.
Correct Answer: C
Rationale: The correct answer is C: 'The condition is incompatible with life.' Anencephaly is the most serious neural tube defect where both hemispheres of the brain are absent. It is incompatible with life, as there are no medical or surgical treatment options available. While some infants with mature brain stem function can maintain vital functions for a short period, anencephaly is ultimately not survivable. Choice A is incorrect as there are no treatment options for anencephaly. Choice B is incorrect as immediate surgery is not necessary for this condition. Choice D is incorrect as an infant with anencephaly will not have permanent disabilities since the condition is not compatible with life.
A major reason for the development of respiratory distress syndrome in the preterm infant is:
- A. Excessive surfactant
- B. Lack of surfactant
- C. Immature immune system
- D. Lack of body fat
Correct Answer: B
Rationale: The correct answer is B: Lack of surfactant. Respiratory distress syndrome (RDS) in preterm infants is primarily due to a lack of surfactant, which is crucial for keeping the lungs inflated. Without adequate surfactant, the alveoli collapse, leading to breathing difficulties. Choice A, Excessive surfactant, is incorrect as RDS is caused by an insufficient amount of surfactant. Choice C, Immature immune system, and Choice D, Lack of body fat, are not directly related to the development of respiratory distress syndrome in preterm infants.
Which explains the importance of detecting strabismus in young children?
- A. Color vision deficit may result.
- B. Amblyopia, a type of blindness, may result.
- C. Epicanthal folds may develop in the affected eye
- D. Corneal light reflexes may fall symmetrically within each pupil
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Rectal temperatures are indicated in which situation?
- A. In the newborn period
- B. Whenever accuracy is essential
- C. Rectal temperatures are never indicated
- D. When rapid temperature changes are occurring
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?
- A. The dorsal gluteal muscle
- B. The vastus lateralis muscle
- C. The ventral gluteal muscle
- D. The biceps muscle
Correct Answer: B
Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.