The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?

Suggest placing the iron drops in the orange juice and then feeding the infant.

Give the mother positive feedback about the way she administered the medication.

Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.

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

Answer and Explanation

The Correct Answer is B

The nurse should give the mother positive feedback about the way she administered the medication. Giving the infant orange juice after administering the iron drops is a good practice because vitamin C in the orange juice can enhance the absorption of iron. The other options (A, C, and D) are not appropriate actions for the nurse to take in this situation.

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Correct Answer is A

Explanation

For an eight-month-old infant with heart failure, the nurse should withhold digoxin if the infant's apical pulse is less than 90 beats/minute and notify the healthcare provider. In this case, the infant's apical pulse is 88 beats/minute, so the nurse should withhold the digoxin and notify the healthcare provider.

Furosemide ( B), hydralazine (C), and enalapril (D) do not have specific parameters for withholding based on the infant's vital signs.

A. The mother states the baby is irritable during feedings. B. The mother is a single parent and lives with her parents. C. The infant's formula has been changed twice. D. The diaper area shows severe skin breakdown.

Correct Answer is D

Explanation

The most significant finding in planning care for this family is that the infant's diaper area shows severe skin breakdown. Severe skin breakdown in the diaper area can be a sign of diaper rash or other skin irritation, which can cause discomfort and disrupt the infant's sleep. Addressing this issue can help improve the infant's comfort and promote beter sleep. The other options (A, B, and C) may also be relevant, but severe skin breakdown in the diaper area is the most significant finding in this situation.

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The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

Correct Answer is D

Explanation

The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving this client?

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The parents of a 14-month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to these parents?

The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?

While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

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