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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.
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The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?
- A. Use the small cuff
- B. Use the large cuff
- C. Use either cuff using the palpation method
- D. Wait to take the blood pressure until a proper cuff can be located
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The parents of a school-age child ask the nurse if she thinks that their child has attention deficit hyperactivity disorder (ADHD). Which statement regarding the child's behavior at school is most indicative of ADHD?
- A. He finishes his work on time in order to go to recess.
- B. He occasionally gets into trouble for talking.
- C. He enjoys math but does not like reading.
- D. He cannot sit still in his seat and constantly moves his legs.
Correct Answer: D
Rationale: The most indicative behavior of ADHD is the inability to sit still and constant movement, known as hyperactivity. This behavior is a hallmark symptom of ADHD, making option D the correct choice. Options A, B, and C do not specifically reflect the characteristic hyperactivity associated with ADHD, making them less indicative of the disorder. While option B suggests impulsivity, it is not as specific to ADHD as the hyperactivity described in option D.
The parents of a child with sickle cell anemia ask why their child did not have a sickle cell crisis until he was approximately 6 months old. How should the nurse respond?
- A. Your child probably had a crisis, and you were unaware of the symptoms.
- B. Are you sure your child has sickle cell anemia and not sickle cell trait?
- C. Affected children can be asymptomatic in early infancy because of high levels of fetal hemoglobin that inhibit sickling.
- D. Have you asked your doctor about this yet?
Correct Answer: C
Rationale: The correct answer is C. Fetal hemoglobin (HbF) is present in high levels during early infancy, inhibiting sickling unlike adult hemoglobin (HbS). As the levels of HbF decrease and HbS increases, the risk of sickling and crises becomes more pronounced, typically after 6 months of age. Choice A is incorrect because it assumes the crisis went unnoticed, which is not supported by medical knowledge. Choice B is incorrect as it questions the child's diagnosis rather than explaining the phenomenon of delayed crises. Choice D is incorrect as it does not provide the parents with the necessary information regarding their query.
The nurse is teaching parents about the effects of media on childhood obesity. The nurse realizes the parents understand the teaching if they make which statements? (Select all that apply.)
- A. Advertising of unhealthy food can increase snacking
- B. Increased screen time may be related to unhealthy sleep
- C. There is a link between the amount of screen time and obesity
- D. All of the above
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which?
- A. Lacking in protein
- B. Indicating they live in poverty
- C. Providing sufficient amino acids
- D. Needing enrichment with meat and milk
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.