Nokea
To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to:
- A. Smile and laugh out loud.
- B. Roll from back to side.
- C. Hold a rattle briefly.
- D. Turn the head from side to side.
Correct Answer: D
Rationale: A 1-month-old can turn their head side to side, a basic motor milestone.
You may also like to solve these questions
When preparing to obtain a neonatal screening test for phenylketonuria (PKU), the neonate must have received which of the following to ensure reliable results?
- A. A feeding of an iron-rich formula.
- B. Nothing by mouth for 4 hours before the test.
- C. Initial formula or breast milk at least 24 hours before the test.
- D. A feeding of glucose water.
Correct Answer: C
Rationale: PKU screening requires protein intake (breast milk or formula) for 24 hours to detect elevated phenylalanine levels. Iron-rich formula, fasting, or glucose water are inadequate.
When teaching a mother about measures to prevent lead poisoning in her children, which of the following preventive measures should the nurse include as the most effective?
- A. Condemning of old housing developments.
- B. Educating the public on common sources of lead.
- C. Educating the public on the importance of good nutrition.
- D. Keeping pregnant women out of old homes that are being remodeled.
Correct Answer: B
Rationale: Education on lead sources (e.g., paint, dust) empowers families to avoid exposure. Condemning housing is impractical, nutrition is secondary, and protecting pregnant women is less broad-reaching.
A child with a peanut allergy is prescribed an epinephrine auto-injector. The nurse should teach the parents to administer it in which situation?
- A. Mild itching after eating peanuts.
- B. Swelling of the lips and tongue.
- C. Upset stomach after exposure.
- D. Fatigue after a meal.
Correct Answer: B
Rationale: Lip and tongue swelling indicates anaphylaxis, requiring immediate epinephrine. Itching, upset stomach, or fatigue are less severe and managed differently.
The parents of an 18-year-old preparing to enter college ask if their daughter should have the meningococcal (MCV4) vaccine. The nurse should tell the parents:
- A. It is only necessary to have the vaccine if your daughter will be living in a dormitory.'
- B. We recommend the vaccine, but it needs to be given as a series of three injections.'
- C. Let's review your records. The vaccine may have already been given a few years ago.'
- D. We highly recommend this vaccine, but we will need to do a pregnancy screening first.'
Correct Answer: C
Rationale: Checking vaccination records confirms whether the MCV4 vaccine, recommended for adolescents, was previously administered.
When performing cardiopulmonary resuscitation (CPR), which of the following indicates that external chest compressions are effective?
- A. Mottling of the skin.
- B. Pupillary dilation.
- C. Palpable pulse.
- D. Cool, dry skin.
Correct Answer: C
Rationale: A palpable pulse during CPR indicates effective chest compressions, as it confirms adequate circulation.