The nurse observes a mother administering ferrous sulfate (iron drops) to her 11-month-old child, followed by 2 ounces (60 mL) of orange juice.

What should be the nurse’s subsequent action?

Advise the mother to follow the iron drops with infant formula instead of orange juice.

Commend the mother on her method of administering the medication.

Propose mixing the iron drops in the orange juice before feeding the infant.

Direct the mother to refrain from feeding the infant for 30 minutes after giving the iron drops.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While infant formula is a common feeding option, it does not enhance the absorption of iron. In fact, iron is better absorbed when taken with vitamin C, which is abundant in orange juice.
Choice B rationale
The mother is correctly administering the iron drops. Giving iron with orange juice can enhance iron absorption due to the vitamin C content.
Choice C rationale
Mixing the iron drops in the orange juice is not necessary and could potentially alter the taste of the juice.
Choice D rationale
There is no need to refrain from feeding the infant for 30 minutes after giving the iron drops.

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Correct Answer is A

Explanation

Choice A rationale
When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the right leg. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage. Changes in peripheral pulses and sensation can indicate potential complications, such as compromised blood flow or nerve compression, which need immediate attention to prevent further damage.
Choice B rationale
While cleansing pin sites as prescribed is important for infection prevention, it is not the most critical intervention in the context of assessing vascular and neurologic status.
Choice C rationale
Assessing skin for redness and signs of tissue breakdown is important for skin care and preventing pressure ulcers, but it is secondary to monitoring peripheral pulses and sensations when the child is in traction.
Choice D rationale
Changing position every 2 hours is a standard nursing practice to prevent pressure ulcers and provide comfort, but it does not take precedence over monitoring circulation and sensation in the affected limb.

A. Surgery should be performed within one month to prevent bladder infections. B. Postponing the repair until the child reaches school age can alleviate fears of castration. C. The repair should be completed before the child is toilet-trained. D. The urethral repair should be carried out after the child reaches sexual maturity.

Correct Answer is C

Explanation

Choice A rationale
While it’s important to prevent bladder infections, performing surgery within one month is not typically recommended for hypospadias.
Choice B rationale
Postponing the repair until the child reaches school age is not typically recommended. The fear of castration is not usually a consideration in the timing of hypospadias repair.
Choice C rationale
The repair should ideally be completed before the child is toilet-trained. This allows for normal urinary function and reduces potential psychological impact.
Choice D rationale
Waiting until the child reaches sexual maturity is not typically recommended. Early intervention allows for normal development and function.

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The nurse observes a mother administering ferrous sulfate (iron drops) to her 11-month-old child, followed by 2 ounces (60 mL) of orange juice. What should be the nurse’s subsequent action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?

Correct Answer is A

Explanation

The parents of a newborn with hypospadias are anxious about the timing of the surgical correction. What information should the nurse share with them?

Correct Answer is C

Explanation

A 9-week-old infant is scheduled for a cleft lip repair. What information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?

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The nurse observes a mother administering ferrous sulfate (iron drops) to her 11-month-old child, followed by 2 ounces (60 mL) of orange juice.

What should be the nurse’s subsequent action?