Nokea
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.
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After teaching a group of nursing students about developmental milestones for children between the ages of 1 and 4 years, the instructor determines that the teaching was successful when the students identify which of the following as a gross motor developmental milestone that occurs between 2 to 3 years of age?
- A. Jumping in place
- B. Climbing
- C. Standing on one foot with help
- D. Riding a tricycle
Correct Answer: B
Rationale: Climbing is a gross motor milestone typically achieved between 2 to 3 years of age. It involves coordination and strength. Jumping in place is usually mastered around 2 years of age. Standing on one foot with help is a skill that emerges around 3 years. Riding a tricycle typically occurs closer to 3 years and involves coordination and balance, which are more refined skills compared to climbing at an earlier age.
A 3-year-old child, previously potty-trained, becomes a bed-wetter again during a hospital stay. Which explanation should the nurse provide to the parents?
- A. "Your child is no longer potty-trained and will need to be retrained when she goes home."
- B. "The child may have developed a bladder infection in the hospital. I will notify the doctor."
- C. "Preschool children may regress in their behaviors when they are ill in the hospital but should return to normal when they go back home."
- D. "Don't worry about it, she is fine."
Correct Answer: C
Rationale: During a hospital stay, preschool children may exhibit regression in behaviors such as bed-wetting due to stress. It is important for parents to understand that this behavior is a common response to the hospital environment and should resolve once the child is back home. Therefore, the correct explanation for the nurse to provide to the parents is choice C. Choice A is incorrect because it inaccurately states that the child is no longer potty-trained. Choice B is incorrect as it assumes a medical issue without evidence. Choice D is incorrect as it dismisses the parents' concerns without addressing the underlying cause of the behavior.
The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?
- A. Ask the parent when the neck was injured
- B. Refer for immediate medical evaluation
- C. Continue assessment to determine the cause of the neck pain
- D. Record head lag on the assessment record and continue the assessment of the child
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.
At what age is binocularity, the ability to fixate on one visual field with both eyes simultaneously, typically achieved?
- A. 1 month
- B. 3 to 4 months
- C. 6 to 8 months
- D. 12 months
Correct Answer: B
Rationale: Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is typically achieved by the age of 3 to 4 months. Achieving binocularity at 1 month is too early for most infants as their visual system is still developing. Similarly, 6 to 8 months and 12 months are beyond the normal age range for achieving binocularity, and delayed achievement could indicate potential issues like strabismus, which may lead to visual impairment if not addressed.