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Which of the following immunizations should the nurse plan to administer?
- A. Measles, mumps, and rubella (MMR)
- B. Varicella (VAR)
- C. Rotavirus (RV)
- D. Herpes zoster
- E. Human papillomavirus (HPV4)
Correct Answer: A,B
Rationale: The correct answer is A (MMR) and B (VAR). These immunizations are recommended for certain age groups to prevent measles, mumps, rubella, and varicella. MMR provides protection against three viral infections, while VAR protects against chickenpox. These vaccinations are part of the routine childhood immunization schedule to prevent the spread of these contagious diseases. Rotavirus (C) is given to infants to protect against a common cause of severe diarrhea, while Herpes zoster (D) and Human papillomavirus (E) are not typically administered by nurses in routine practice.
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Specify 2 actions the nurse should take to address that condition.
- A. Anticipate a prescription for digoxin.
- B. Elevate the head of the bed to a 45° angle.
- C. Implement contact precautions.
- D. Provide chest physiotherapy and postural drainage.
Correct Answer: A,B
Rationale: The correct answers are A and B. A nurse should anticipate a prescription for digoxin as it is commonly prescribed for heart failure to improve heart function. Elevating the head of the bed to a 45° angle helps reduce the workload on the heart and improve respiratory function. Choice C, implementing contact precautions, is unrelated to addressing the condition. Choice D, providing chest physiotherapy and postural drainage, is not typically indicated for heart failure.
Which of the following actions should the nurse take?
- A. Administer chlorothiazide.
- B. Hold the child down.
- C. Place the child in a prone position.
- D. Time the episode.
Correct Answer: D
Rationale: The correct action is D: Time the episode. By timing the episode, the nurse can gather important data to assess the duration and severity of the situation, aiding in diagnosis and treatment planning. Administering chlorothiazide (A) without assessing the situation first could be harmful. Holding the child down (B) may escalate the situation and cause distress. Placing the child in a prone position (C) could worsen their condition. Timing the episode (D) is essential for accurate evaluation.
Which of the following findings should the nurse report to the provider?
- A. Unable to roll from back to abdomen
- B. Exhibits head lag when pulled to a sitting position
- C. Unable to hold a bottle
- D. Absent grasp reflex
Correct Answer: B
Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, a developmental milestone typically achieved around 4 months. Reporting this to the provider is crucial for further assessment and intervention. Choice A is incorrect as rolling from back to abdomen is typically achieved around 5-6 months. Choice C is incorrect as holding a bottle is a milestone around 6-10 months. Choice D is incorrect as the grasp reflex typically disappears around 3-4 months. The key is to identify the finding that deviates significantly from the expected developmental milestone, which is demonstrated by choice B.
Which of the following information should the nurse include in the teaching?
- A. Place an infant who is 5 months old in a high chair to feed.
- B. Position a 1-month-old infant supine on a soft mattress.
- C. Provide an infant with a one-piece pacifier for non-nutritive sucking.
- D. Secure the infant's car seat behind an airbag.
Correct Answer: C
Rationale: The correct answer is C because providing an infant with a one-piece pacifier for non-nutritive sucking reduces the risk of choking and aspiration compared to multi-piece pacifiers. This information is crucial for infant safety during feeding. Choice A is incorrect as a 5-month-old infant should be seated in a high chair only if they can sit upright without support to prevent falls. Choice B is incorrect as placing a 1-month-old infant supine on a soft mattress increases the risk of sudden infant death syndrome (SIDS). Choice D is incorrect as securing an infant's car seat behind an airbag can be dangerous due to the risk of injury from the airbag deployment.
The nurse should immediately report which of the following findings to the provider?
- A. Rhinorrhea
- B. Pharyngitis
- C. Coughing
- D. Tachypnea
Correct Answer: D
Rationale: The correct answer is D: Tachypnea. Tachypnea, which is rapid breathing, can indicate respiratory distress or an underlying serious condition that requires immediate attention. Reporting this finding promptly is crucial to ensure timely intervention. Rhinorrhea, pharyngitis, and coughing are common symptoms that may not require urgent attention as they can be managed symptomatically. In summary, tachypnea is the most concerning symptom that warrants immediate reporting, while the other choices are less urgent and can be addressed in due course.