The nurse is caring for a 9-month-old child.
The nurse assesses the baby and finds all of the following data.
Which finding is of MOST concern and leads the nurse to consider a possible referral to Early intervention for developmental delay?

Inability to pick up crackers with thumb and forefinger.

Playing with a toy for only a few minutes.

Ability to crawl on all fours supported on hands and knees.

Inability to pull self to a standing position.

Answer and Explanation

The Correct Answer is A

Choice A rationale

By 9 months, most babies have developed the fine motor skills necessary to pick up small objects, like crackers, with their thumb and forefinger. This is known as the pincer grasp. If a 9- month-old child is unable to do this, it could be a sign of a developmental delay.

Choice B rationale

It’s normal for babies at this age to have a short attention span. They often play with a toy for only a few minutes before moving on to something else. Therefore, this behavior is not typically a cause for concern.

Choice C rationale

The ability to crawl on all fours supported on hands and knees is a typical developmental milestone for a 9-month-old child. Therefore, this behavior is expected and does not indicate a developmental delay.

Choice D rationale

While some 9-month-old babies may be able to pull themselves to a standing position, not all babies develop this skill at the same time. Therefore, the inability to do this is not necessarily a cause for concern.

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Correct Answer is B

Explanation

Choice A rationale

Distracting the patient and then taking the blanket for washing might seem like a practical solution, but it can lead to trust issues. The patient may feel betrayed or tricked, which can negatively affect the therapeutic relationship between the nurse and the patient.

Choice B rationale

Acknowledging that the blanket seems to be his favorite and allowing him to keep it with him is the best course of action. The blanket likely provides comfort and security to the patient.

Taking it away, even temporarily, can cause distress. The nurse should respect the patient’s attachment to the blanket and look for alternative solutions for maintaining hygiene, such as offering to clean the blanket when the patient is ready to part with it temporarily.

Choice C rationale

Telling the patient that you want to take the blanket home to wash and that you will bring it back might not be reassuring enough for the patient. The patient may worry about the blanket getting lost or not returned, which can cause unnecessary anxiety.

Choice D rationale

Suggesting getting him another blanket so that he will not mind giving up the current one might not work. The patient’s attachment is likely to the specific blanket, not to blankets in general. A new blanket will not have the same familiarity and comforting effect as the old one.

A. “The medication is a bronchodilator, which opens airways.”. B. “The medication will thin the child’s mucus.”. C. “The medication will reduce wheezing.”. D. “The medication will help with coughing and shortness of breath.”. .

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

Explanation

Choice A rationale

Albuterol is a bronchodilator, which means it relaxes the muscles around the airways, allowing them to open up, or dilate. This makes it easier for air to get in and out of the lungs, and for mucus to be cleared out of the airways.

Choice B rationale

Albuterol does not thin the mucus. Other medications, such as hypertonic saline or dornase alfa, are used in cystic fibrosis to thin the mucus and make it easier to cough up.

Choice C rationale

By opening the airways, albuterol can help reduce wheezing, a high-pitched whistling sound that occurs when airways are narrowed.

Choice D rationale

Albuterol can help relieve symptoms of asthma, such as coughing and shortness of breath, by relaxing the muscles of the airways and increasing airflow.

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The nurse is caring for a 9-month-old child.The nurse assesses the baby and finds all of the following data.Which finding is of MOST concern and leads the nurse to consider a possible referral to Early intervention for developmental delay?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient arrives at the hospital with a stained, ragged baby blanket.When his mother tries to remove the blanket to take it home for washing, he hides under the bed and clings to the blanket.What is the best course of action for the nurse?

Correct Answer is B

Explanation

A nurse is caring for a child with asthma who is prescribed to use an albuterol inhaler with a spacer. The parents ask how albuterol helps the child’s breathing.Which of the following responses should the nurse include? (Select all that apply)

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

Explanation

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The nurse is caring for a 9-month-old child.The nurse assesses the baby and finds all of the following data.Which finding is of MOST concern and leads the nurse to consider a possible referral to Early intervention for developmental delay?

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A nurse is caring for a child with asthma who is prescribed to use an albuterol inhaler with a spacer. The parents ask how albuterol helps the child’s breathing.Which of the following responses will the nurse include? Select all that apply.

The nurse is caring for a 9-month-old child.
The nurse assesses the baby and finds all of the following data.
Which finding is of MOST concern and leads the nurse to consider a possible referral to Early intervention for developmental delay?