Nokea
Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner?
- A. Infant refuses a feeding
- B. Infant has an axillary temperature of 97°F
- C. Infant has three pasty, yellow-brown stools in 24 hours
- D. Infant's diaper is not wet after 8 hours
Correct Answer: D
Rationale: Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration.
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The nurse is preparing to administer vaccines to a 4-month-old infant. Which vaccines should the nurse prepare? (Select one that does not apply.)
- A. DTaP
- B. MMR
- C. IPV
- D. Hib
Correct Answer: B
Rationale: At 4 months, per CDC guidelines, infants receive DTaP (diphtheria, tetanus, pertussis), IPV (inactivated poliovirus), and Hib (Haemophilus influenzae type b). MMR and Varicella are typically given at 12-15 months.
Mother Riza brings her normally developed 3-year old to the clinic for a check-up. The nurse would expect that the child would be at least skilled in...
- A. Riding a bicycle
- B. Tying shoelaces
- C. Stringing large beads
- D. Using blunt scissors
Correct Answer: C
Rationale: Stringing large beads is a fine motor skill expected of a 3-year-old.
A hospitalized school age states: 'I'm not afraid of this place, I'm not afraid of anything.' This statement is most likely an example of which of the following?
- A. Regression
- B. Repression
- C. Reaction formation
- D. Rationalization
Correct Answer: C
Rationale: Reaction formation involves expressing the opposite of true feelings to cope; the child’s bold statement likely masks fear, typical in school-age children facing hospitalization.
In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the nurses first action?
- A. Ask if the patient has taken a sedative.
- B. Notify the physician.
- C. Turn the patient to her right side.
- D. Record the rate as a normal finding.
Correct Answer: D
Rationale: The FHR at term ranges from a low of 110 to 120 beats/min to a high of 150 to 160 beats/min. This should be recorded as normal. The FHR drops in the late stages of pregnancy.
What is the total number of chromosomes contained in a mature sperm or ovum?
- A. 22
- B. 23
- C. 44
- D. 46
Correct Answer: B
Rationale: Gametes (sex chromosomes) contain 23 chromosomes.