A nurse is assessing a one-month-old infant.
Which of the following findings should the nurse report to the provider?

Inability to sit without support.

Inability to raise head when in prone position.

Inability to bring an object to mouth.

Inability to pick up an object with fingers.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale

At one month of age, infants are not expected to sit without support. Therefore, an inability to do so would not be a cause for concern at this age.

Choice B rationale

By one month, infants should be able to briefly raise their head when placed in a prone (on their stomach) position. If an infant is unable to do this, it could indicate a potential developmental delay or muscle weakness.

Choice C rationale

At one month, infants typically have not yet developed the coordination to bring an object to their mouth. Therefore, an inability to do so at this age would not be a cause for concern.

Choice D rationale

By one month, infants are not expected to have the fine motor skills necessary to pick up an object with their fingers. Therefore, an inability to do so would not be a cause for concern at this age.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Pain management is crucial after a tonsillectomy. Pain can prevent children from eating or drinking, leading to dehydration. Therefore, ensuring that the child’s pain is well managed is an important part of post-operative care.

Choice B rationale

Mild ear pain or bad breath after surgery can be signs of complications such as infection. Therefore, parents should be instructed to report these symptoms if they occur.

Choice C rationale

After a tonsillectomy, the throat is often sore and swollen. Eating soft foods can help prevent further irritation or injury to the throat. Crunchy foods could scratch the healing throat and cause discomfort.

Choice D rationale

While it’s true that scabs will form on the tonsils as they heal, it’s important to monitor them. If a scab dislodges too early, it can cause bleeding. Therefore, this statement is not entirely accurate and should not be included in the discharge instructions.

A. These therapies will decrease our child’s resistance to respiratory infections. B. These therapies will only be done when our child is showing signs of illness. C. These therapies will help to loosen our child’s secretions and allow for better expectoration. D. These therapies will allow for the removal of mucus from our child’s GI tract that blocks digestion.

Correct Answer is C

Explanation

Choice A rationale

These therapies will decrease our child’s resistance to respiratory infections. This statement is incorrect. The therapies mentioned - chest physiotherapy (CPT), use of a flutter valve, and a cough assist machine - do not directly decrease a child’s resistance to respiratory infections.

Instead, they help manage the symptoms of cystic fibrosis by helping to clear mucus from the lungs, which can improve lung function and reduce the risk of lung infections.

Choice B rationale

These therapies will only be done when our child is showing signs of illness. This statement is incorrect. These therapies are part of the daily management of cystic fibrosis and are typically done regularly, not just when the child is showing signs of illness.

Choice C rationale

These therapies will help to loosen our child’s secretions and allow for better expectoration. This statement is correct. The goal of these therapies is to help clear thick, sticky mucus from the lungs, which can improve breathing and reduce the risk of lung infections.

Choice D rationale

These therapies will allow for the removal of mucus from our child’s GI tract that blocks digestion. This statement is incorrect. While cystic fibrosis can affect the digestive system by causing thick mucus to block the tubes that carry digestive enzymes from your pancreas to your small intestine, the therapies mentioned are primarily used to help clear mucus from the lungs.

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A nurse is assessing a one-month-old infant.Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What instructions should the nurse include in the post-operative discharge instructions for a 6-year-old who just had a tonsillectomy? (Select All That Apply)

Correct Answer is ["A","B","C"]

Explanation

The parents of a 7-year-old recently diagnosed with cystic fibrosis have received discharge instructions for chest physiotherapy (CPT), use of a flutter valve, and a cough assist machine.Which of the following statements by the parents indicates understanding of the discharge instructions?

Correct Answer is C

Explanation

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A nurse is assessing a one-month-old infant.
Which of the following findings should the nurse report to the provider?