The nurse is caring for a 4-month-old infant in the emergency department. The nurse reviews the infant's medical record and assessment findings. Which of the following conditions should the nurse suspect, and what actions should the nurse take to address that condition, and what parameters should the nurse monitor to assess the infant's progress?

The nurse should suspect that the infant has

failure to thrive.

microcephaly.

hydrocephalus.

macrocephaly.

Answer and Explanation

The Correct Answer is C

Choice A reason: Failure to thrive is not a likely condition, as it is a term used to describe inadequate growth or weight gain in children. The infant has a low weight percentile, but not below the 5th percentile, which is the usual cutoff for failure to thrive. The infant's length and head circumference are within the normal range, which also does not indicate failure to thrive.

Choice B reason: Microcephaly is not a probable condition, as it is a condition where the head size is much smaller than normal for the age and sex of the child. The infant has a high head circumference percentile, which is the opposite of microcephaly. Microcephaly can be caused by genetic disorders, infections, or brain damage.

Choice C reason: Hydrocephalus is a possible condition, as it is a condition where excess cerebrospinal fluid accumulates in the brain, causing increased pressure and enlargement of the head. The infant has a high head circumference percentile, which can indicate hydrocephalus. The infant also has a low weight percentile, which can be a result of poor feeding or vomiting due to increased intracranial pressure. T

Choice D reason: Macrocephaly is not a definite condition, as it is a term used to describe a head size that is much larger than normal for the age and sex of the child. The infant has a high head circumference percentile, but not above the 97th percentile, which is the usual cutoff for macrocephaly. Macrocephaly can be caused by genetic factors, benign familial macrocephaly, or other conditions, such as hydrocephalus.

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Correct Answer is A

Explanation

Choice A reason: This is a contraindication for the MMR immunization, which is a live attenuated vaccine. A child who has a congenital immunodeficiency may not be able to mount an adequate immune response to the vaccine and may be at risk of developing the diseases from the vaccine.

Choice B reason: This is not a contraindication for the MMR immunization. A mild fever after a previous immunization is not a sign of an allergic reaction or a serious adverse effect. The child can still receive the MMR immunization as long as they do not have a moderate or severe illness.

Choice C reason: This is not a contraindication for the MMR immunization. Taking antibiotics for otitis media does not interfere with the effectiveness or safety of the vaccine. The child can still receive the MMR immunization as long as they do not have a moderate or severe illness.

Choice D reason: This is not a contraindication for the MMR immunization. A mild cough and a low-grade fever are not signs of a moderate or severe illness that would prevent the child from receiving the vaccine. The child can still receive the MMR immunization as long as they do not have any other contraindications.

A. The reason why the child is taking the medication B. The adverse effects of the medication C. Stopping the medication when the child feels better D. Written information about the medication E. Using a kitchen spoon to administer the medication

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

Explanation

Choice A: The reason why the child is taking the medication

It is essential for the nurse to explain why the child is taking the medication. This helps the parents or caregivers understand the importance of the medication and ensures they are more likely to adhere to the prescribed treatment plan. Knowing the reason for the medication can also help in recognizing the signs of improvement or any potential issues that may arise during the course of treatment.

Choice B: The adverse effects of the medication

Informing the parents or caregivers about the potential adverse effects of the medication is crucial. This knowledge allows them to monitor the child for any side effects and seek medical attention if necessary. It also helps in managing expectations and reduces anxiety if any common side effects occur.

Choice C: Stopping the medication when the child feels better

This is not a correct choice. It is important to complete the full course of antibiotics as prescribed, even if the child starts feeling better. Stopping the medication prematurely can lead to incomplete treatment of the infection and may contribute to antibiotic resistance.

Choice D: Written information about the medication

Providing written information about the medication is important as it serves as a reference for the parents or caregivers. This information can include dosage instructions, potential side effects, and any other relevant details. Written instructions help ensure that the medication is administered correctly and consistently.

Choice E: Using a kitchen spoon to administer the medication

This is not a correct choice. Using a kitchen spoon to administer medication is not recommended as it can lead to inaccurate dosing. It is important to use a proper measuring device, such as an oral syringe or a medication cup, to ensure the correct dosage is given.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer the first measles, mumps, and rubella (MMR) immunization to a 15-month-old toddler. Which of the following findings is a contraindication for this immunization?

Correct Answer is A

Explanation

A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of the following information should the nurse include in the discharge instructions? (Select all that apply.)

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

Explanation

A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first?

A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan?

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?

A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect?

A nurse in a pediatric clinic is talking with the mother of a preschool-age child. The mother tells the nurse that her son is a "picky eater." Which of the following instructions should the nurse include in the teaching?

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?