A nurse is discussing growth and development milestones with the parents of a 3-year-old preschooler. Which of the following statements by a parent indicates to the nurse that the preschooler is meeting the expected benchmarks of other preschoolers in this age group?

"My child uses scissors to cut out the outline of an object.”

"My child can copy triangle shapes onto paper.”

"My child can ride a tricycle.”

"My child can throw a ball overhead.”

Answer and Explanation

The Correct Answer is B

Choice A reason:

If the parent states, "My child uses scissors to cut out the outline of an object,” this indicates fine motor skills development. While this is a positive milestone, it is not specific to the expected benchmarks of other preschoolers in this age group. The ability to cut out shapes with scissors varies widely among preschoolers.

Choice B reason:

"My child can copy triangle shapes onto paper.” This statement shows that the child can demonstrate some level of visual-motor coordination and fine motor skills. Copying shapes like triangles is a common milestone for many preschoolers at the age of 3 and is considered an expected benchmark.

Choice C reason:

If the parent says, "My child can ride a tricycle,” this indicates gross motor skills development. Riding a tricycle is also a milestone achieved by many preschoolers, but it may not be as specific to the expected benchmarks of this age group as choice B, which focuses on fine motor skills and visual-motor coordination.

Choice D reason:

If the parent mentions, "My child can throw a ball overhead,” this also points to gross motor skills development. While throwing a ball overhead is an impressive skill for a 3-year-old, it may not be as common or consistent among all preschoolers in this age group as the ability to copy triangle shapes onto paper (choice B).

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Correct Answer is D

Explanation

Choice A reason:

The nurse should not reinforce to the client that they should not breastfeed after delivery. Group B streptococcus (GBS) is not transmitted through breast milk. It is crucial for infants born to GBS-positive mothers to receive appropriate prophylaxis, but breastfeeding is not contraindicated.

Choice B reason:

The nurse should maintain contact precautions for the client. Group B streptococcus is a highly contagious bacterium, and taking precautions can help prevent its transmission to other patients and healthcare workers.

Choice C reason:

The nurse does not need to obtain a pharyngeal culture from the client. Group B streptococcus colonization typically occurs in the genital and gastrointestinal tracts, not in the pharynx. Therefore, a pharyngeal culture would not be relevant in this situation.

Choice D reason:

This is the correct action the nurse should take. The client tested positive for group B streptococcus, which puts the newborn at risk of infection during labor and delivery. The standard protocol is to administer intravenous antibiotic prophylaxis to the mother during labor to reduce the risk of transmission to the baby.

A. Remind the client to void every 4 hr. B. Encourage the client to alternate from side to side every 2 hr. C. Raise the four side rails on the client's bed. D. Monitor the client's blood pressure.

Correct Answer is D

Explanation

Choice A reason:

The nurse should not remind the client to void every 4 hours because epidural anesthesia can cause temporary loss of bladder sensation, making it difficult for the client to know when to void. Instead, the nurse should use a bladder scanner to assess for urinary retention and encourage the client to void regularly.

Choice B reason:

Encouraging the client to alternate from side to side every 2 hours is not directly related to the administration of epidural anesthesia. This action is commonly advised for clients who are on bed rest to prevent pressure ulcers and promote circulation. However, it is not specifically necessary for the client receiving epidural anesthesia for pain management during labor.

Choice C reason:

Raising the four side rails on the client's bed is not necessary in this situation. The use of side rails should be based on the client's mobility and risk assessment for falls. If the client is receiving epidural anesthesia, they may experience reduced mobility, but the decision to use side rails should be made on an individual basis, not solely based on the anesthesia.

Choice D reason:

Monitoring the client's blood pressure is a crucial action when a client is receiving epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, leading to hypotension. By regularly monitoring the client's blood pressure, the nurse can detect any significant changes and take appropriate actions to maintain hemodynamic stability.

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A nurse is discussing growth and development milestones with the parents of a 3-year-old preschooler. Which of the following statements by a parent indicates to the nurse that the preschooler is meeting the expected benchmarks of other preschoolers in this age group?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and tested positive for group B streptococcus B- hemolytic. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who is receiving epidural anesthesia for pain management during labor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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