The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuﬀed toy. Which intervention should the nurse implement?

Obtain the essential information as quickly as possible.

Document interactions between the parent and the child.

Ignore the child's behavior, directing questions to a parent.

Include the child's toy in the collection of information.

Answer and Explanation

The Correct Answer is D

The nurse should implement the intervention of including the child's toy in the collection of information when the child screams and tries to hide behind the parent, dropping a stuﬀed toy. This can help engage the child and make them feel more comfortable during the medical history collection process. The other options (A, B, and C) are not appropriate interventions in this situation.

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Correct Answer is C

Explanation

The startle reﬂex, also known as the Moro reﬂex, is a normal reﬂex in infants that is present at birth and usually disappears by 3-4 months of age. The reﬂex is elicited by a sudden loud noise or change in position, and the infant will extend their arms and legs, then bring them back in towards their body.

If a 6-month-old infant is still demonstrating the startle reﬂex, it may indicate a developmental delay or neurological issue and requires further evaluation by the nurse or healthcare provider.

The other responses are all normal developmental milestones for a 6-month-old infant. By 6 months of age, most infants will have doubled their birth weight, enjoy playing games like peek-a-boo, and have developed the ability to turn their head to locate sounds.

A. Fever of 101.0°F (38.3°C) B. Cries often when nursing C. Difficulty swallowing secretions. D. Barking cough, worse at night

Correct Answer is C

Explanation

When advising a new mother on caring for a child with croup, the telephone triage nurse should prioritize concern for difficulty swallowing secretions. This symptom can indicate that the child's airway is becoming obstructed and requires immediate medical attention. A fever of 101.0°F (38.3°C) is a common symptom of croup and can be managed at home with antipyretics. Crying often when nursing is not a specific symptom of croup and may have other causes. A barking cough, worse at night, is a characteristic symptom of croup and can be managed at home with humidified air and hydration.

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The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuﬀed toy. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Correct Answer is C

Explanation

When advising a new mother on caring for a child with croup, which symptom should be a priority concern for the telephone triage nurse?

Correct Answer is C

Explanation

The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?

The nurse is caring for a child with sickle cell disease who is experiencing a sickle cell crisis. Which finding should the nurse report to the healthcare provider immediately?

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