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A nurse is caring for a 4-month-old infant in the outpatient setting.

Exhibits

Which of the following should the nurse identify as unexpected findings? Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Body system

Findings

Vital Signs

Temperature 36.9°C (98.4° F)

Heart rate 162/min

Respiratory rate 28/min

Oxygen saturation 97% on room air

Gastrointestinal

Also spits up after every feeding, sometimes forcefully. Infant is formula fed and recently began refusing some feedings.

Bowel sounds normoactive.

Small, soft, midline bulge observed on abdomen between xyphoid process and umbilicus.

Weight 5,925 g (13 lb 1 oz). Parents report birth weight was 4,196 g (9 lb 4 oz).

Temperature 36.9°C (98.4° F)

Heart rate 162/min

Respiratory rate 28/min

Also spits up after every feeding, sometimes forcefully

Small, soft, midline bulge observed on abdomen between xyphoid process and umbilicus

Weight 5,925 g (13 lb 1 oz). Parents report birth weight was 4,196 g (9 lb 4 oz)

Answer and Explanation

The Correct Answer is ["B","D","E"]

Heart rate 162/min: Elevated for a 4-month-old at rest; tachycardia can indicate dehydration, fever, or stress.

Spits up forcefully after feedings: Forceful vomiting can suggest gastroesophageal reflux disease (GERD) or pyloric stenosis.

Small, soft midline bulge: Likely an umbilical hernia; may need monitoring or intervention if persistent or large.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. 6 months: At this age, infants typically coo and babble but do not form words.
B. 10 months: Infants might say "mama" or "dada," but their vocabulary is usually less than 10 words.
C. 18 months: By 18 months, most children have a vocabulary of approximately 10–20 words.
D. 24 months: By 24 months, children typically have a vocabulary of about 50 words or more and begin forming two-word phrases.

A. "I will ensure that my child takes a 1 hour nap each day." B. "I will give my child prednisone as needed for pain." C. "I will apply cool compresses to my child's painful joints during exacerbations." D. "I will have my child wear splints during the night."

Correct Answer is D

Explanation

A. "I will ensure that my child takes a 1-hour nap each day." Prolonged inactivity, like frequent naps, may increase joint stiffness. Physical activity should be encouraged to maintain joint mobility.
B. "I will give my child prednisone as needed for pain." Prednisone is not typically used as needed for pain. NSAIDs are the first-line treatment for inflammation and pain in JIA.
C. "I will apply cool compresses to my child's painful joints during exacerbations." Warm compresses, not cool, are typically more effective in relieving joint stiffness in JIA.
D. "I will have my child wear splints during the night." Wearing splints at night helps maintain joint position and prevent contractures.

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A nurse is teaching a group of new parents about expected language development. The nurse should include that a child should begin to speak 10 or more words at about which of the following ages?

Correct Answer is C

Explanation

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Correct Answer is D

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