Nokea
A nurse is assessing a 4-month-old infant during a well-child visit. Which of the following findings will require the nurse to collect additional information?
- A. The infant’s shirt is wet from drooling.
- B. The infant has gained one pound since her 2-month well-child visit.
- C. The infant holds his or her head steady when in a sitting position.
- D. The infant grasps objects with two hands.
Correct Answer: B
Rationale: A weight gain of only 1 pound in 2 months is below the expected growth, suggesting a need for further assessment.
You may also like to solve these questions
A nurse working with a Hispanic family is explaining the plan for managing a child’s asthma to the child’s mother, father, and grandmother. To whom should the nurse direct the education?
- A. Mother
- B. Father
- C. Grandmother
- D. Parents and grandmother
Correct Answer: D
Rationale: In Hispanic cultures, all adults, including elders, may play a role in decision-making, so education should be directed to all.
A community nurse has collected rates of alcohol-related motor vehicle accidents involving teenagers. Which action should the nurse take next?
- A. Develop a plan to address the high rates of alcohol-related motor vehicle accidents.
- B. Partner with high school nurses to educate students about the risks of drinking and driving.
- C. Diagnose the community with ineffective health management patterns related to the high levels of drunk driving.
- D. Establish support groups for teenagers with alcohol abuse.
Correct Answer: C
Rationale: Diagnosing the community with ineffective health management patterns follows the data collection and analysis phase.
A client who is 36 weeks of gestation is at her prenatal visit. The nurse tells the client that she will be screened for group B Streptococcus during today’s visit. Which of the following statements would be made by the nurse when providing client education about this screening test?
- A. “Screening for group B Streptococcus is necessary as this infection can cause complications with pregnancy and to the unborn infant.”
- B. “This screening will help us to determine if your unborn infant will be susceptible to respiratory distress when he or she is born.”
- C. “Screening for group B Streptococcus will help us identify if you have been exposed to this or any other infections during your pregnancy.”
- D. “This screening is necessary to determine if there is any Rh blood group incompatibility between you and your unborn child.”
Correct Answer: A
Rationale: Group B Streptococcus screening is important as this infection can lead to severe complications for the infant.
A nurse is assessing a woman for positive signs of pregnancy. Which of the following assessment findings would the nurse discover?
- A. Positive test for HCG in the maternal urine
- B. Detection of fetal heart tones
- C. Enlargement of the uterus
- D. Palpation of fetal body parts
Correct Answer: B
Rationale: Positive signs of pregnancy include detection of fetal heart tones and palpation of fetal body parts.
Which is an example of asymptomatic pathogenesis?
- A. Blood pressure of 170/98 experiencing headaches
- B. Positive finding on colonoscopy and blood in stool
- C. Elevated prostate-specific antigen (PSA)
- D. Elevated TSH who is always tired
Correct Answer: C
Rationale: Elevated PSA without symptoms is an example of asymptomatic pathogenesis, where the disease is present but not yet manifested.