Question

A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hr as needed. The amount available is diphenhydramine elixir 12.5 mg/5 ml. How many ml. should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 1

Correct Answers:

10

Rationale :

💠Ordered dose = 25 mg

💠Available concentration = 12.5 mg in 5 mL

💠Set up the proportion:

12.5 mg → 5 mL

25 mg → X mL

💠Solve for X:

X = (25 mg × 5 mL) ÷ 12.5 mg

X = 125 ÷ 12.5

💠 X = 10 mL

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Regression

Rationale :

🔷 Regression is a common response in toddlers during prolonged hospitalization or separation from their primary caregiver.

🔷 Behaviors such as thumb-sucking, quiet withdrawal, and avoiding interaction reflect a return to earlier, more comforting developmental stages.

🔷 Toddlers regress when stressed because familiar behaviors provide emotional security when they feel overwhelmed.

🔷 This behavior does not indicate rejection of the nurse or anger toward the mother; it is a typical coping mechanism seen in hospitalized toddlers.

Resentment toward the mother

🔷 Toddlers experiencing prolonged separation often show attachment behaviors, not resentment.

🔷 This presentation is more consistent with detachment or regression, not anger.

Developing autonomy

🔷 Developing autonomy involves assertiveness, exploration, and independence—not withdrawal or thumb-sucking.

🔷 These behaviors signal stress, not growing independence.

An anxiety reaction

🔷 Anxiety in toddlers is usually shown through crying, clinging, or separation distress, not quiet withdrawal and regression.

🔷 The observed behaviors are more strongly aligned with regression.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Provide a latex-free environment.

Rationale :

🔷 Infants with spina bifida have a very high risk of developing a latex allergy due to repeated early exposure during medical care.

🔷 A latex-free environment prevents allergic reactions, which can range from mild skin irritation to severe anaphylaxis.

🔷 Latex products such as gloves, catheters, and medical equipment must be replaced with latex-free alternatives for safety.

🔷 Preventing latex exposure is a critical priority before and after surgical closure of the myelomeningocele sac to avoid complications.

Limit visitors to immediate family members

🔷 There is no infection-related reason to restrict visitors for infants with spina bifida, as the condition is not contagious.

🔷 Visitor restriction does not affect surgical recovery or safety.

Initiate contact precautions

🔷 Spina bifida is a structural defect, not an infectious disease; therefore, contact precautions are not required.

🔷 Standard precautions are appropriate unless another condition is present.

Maintain the infant in the supine position

🔷 The infant should be kept in the prone (belly-down) position to protect the myelomeningocele sac from pressure and rupture, not supine.

🔷 Supine positioning increases the risk of sac injury and infection.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Clear the respiratory tract

Rationale :

🔷 The first priority immediately after birth is to clear the newborn’s airway to ensure effective breathing.

🔷 Removing mucus or amniotic fluid from the mouth and nose helps prevent airway obstruction and promotes adequate oxygenation.

🔷 Once the airway is clear, additional steps such as drying, warming, and stimulating the newborn can safely follow.

🔷 Airway patency is the foundation of newborn stabilization and must occur before any other interventions.

Dry the infant off and cover the head

🔷 Drying and warming the infant helps prevent heat loss, but it is not the first priority if the airway has not yet been cleared.

🔷 Airway comes before thermoregulation in immediate post-delivery care.

Cut the umbilical cord

🔷 Cutting the cord is not an emergency action and should occur after the newborn is breathing adequately and stabilized.

🔷 It is not the first priority.

Stimulate the infant to cry

🔷 Stimulation should occur after the airway is cleared, not before.

🔷 Crying helps expand the lungs, but blocked airways must be cleared first.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

As some of the contractions peak, the FHR begins to gradually decrease from the baseline and returns gradually to the baseline after the contraction has ended.

Rationale :

🔷 Late decelerations occur when the fetal heart rate gradually decreases after the peak of a contraction and returns to baseline after the contraction ends.

🔷 This pattern indicates uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen during contractions.

🔷 Recurring late decelerations are a non-reassuring finding and require immediate nursing interventions to improve fetal oxygenation.

🔷 The described pattern—decrease beginning at contraction peak and recovery after contraction—matches the definition of late decelerations.

In between contractions, the FHR repeatedly decreases below the baseline to create a tracing that looks like the letter V

🔷 This describes variable decelerations, which are abrupt drops often due to umbilical cord compression.

🔷 Variable decelerations do not follow the contraction pattern like late decelerations do.

The FHR increases above the baseline by 15 beats/min and lasts 20 seconds before decreasing back to the baseline

🔷 This describes a fetal heart rate acceleration, which is reassuring and indicates adequate fetal oxygenation—not distress.

The FHR occasionally drops abruptly from the baseline and returns to the baseline gradually

🔷 Abrupt drops describe variable decelerations, not late decelerations.

🔷 Late decelerations are gradual, not abrupt.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

participating in regular daily weight-bearing exercise

Rationale :

🔷 Weight-bearing exercise, such as walking or jogging, stimulates bone remodeling and helps maintain bone density, which decreases after menopause.

🔷 After menopause, declining estrogen levels increase the risk for osteoporosis, making bone-strengthening activities essential.

🔷 Regular physical activity also improves muscle strength and balance, reducing the risk of falls and fractures.

🔷 This is a primary, evidence-based strategy for lowering osteoporosis risk in postmenopausal clients.

Restricting fluid to 1,000 mL daily

🔷 Fluid restriction does not prevent osteoporosis and may cause dehydration.

🔷 It has no role in maintaining or improving bone health.

Eating high-fiber, high-calorie foods

🔷 High-fiber diets can reduce calcium absorption, and high-calorie intake may lead to weight gain.

🔷 This is not a recommended strategy for osteoporosis prevention.

Taking a multivitamin supplement

🔷 Multivitamins do not contain enough calcium or vitamin D to significantly reduce osteoporosis risk.

🔷 A specific calcium and vitamin D supplement, not a general multivitamin, is usually required.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Ignore the temper tantrums

Rationale :

🔷 Ignoring temper tantrums is an effective strategy because it avoids reinforcing the behavior with attention.

🔷 Toddlers often use tantrums to seek control or gain a response; withholding attention teaches that tantrums are not an effective communication tool.

🔷 This approach helps toddlers learn self-control and encourages the use of appropriate behaviors to express needs.

🔷 Consistency is key—when caregivers ignore tantrums each time, the behavior typically decreases over time.

Tell the child that temper tantrums are not acceptable.

🔷 Toddlers do not yet have the emotional maturity to fully understand verbal reasoning during a tantrum.

🔷 Talking during a tantrum may actually increase attention to the behavior.

Restrain the child physically.

🔷 Physical restraint can escalate distress and may lead to injury or unsafe situations.

🔷 It should only be used if the child is in immediate danger, not as a punishment.

Distract the child by offering to play a game.

🔷 Distracting during a tantrum reinforces the behavior by rewarding it with attention.

🔷 Distraction is more effective when used before tantrums start.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

"We recommend no alcohol during pregnancy for the best outcomes.”

Rationale :

🔷 This response provides clear, evidence-based guidance without judgment, helping the client make a safe and informed decision.

🔷 Alcohol at any point during pregnancy can affect fetal development, so the safest recommendation is complete abstinence.

🔷 The phrasing supports the client emotionally by focusing on positive outcomes, not fear or blame.

🔷 This therapeutic, non-confrontational communication promotes trust and encourages continued dialogue.

"As long as you don't drink in the first trimester, your baby should be okay."

🔷 Alcohol is unsafe at all stages of pregnancy and can contribute to fetal alcohol spectrum disorders.

🔷 This answer gives inaccurate reassurance.

“Why do you want to place your baby's well-being at risk?”

🔷 This response is judgmental and may shut down communication.

🔷 It does not support the client's emotional needs.

"Drinking even small amounts of alcohol can cause your baby's heart to stop beating."

🔷 This statement is inaccurate and fear-based; alcohol does not cause fetal cardiac arrest from a single drink.

🔷 The nurse must avoid exaggeration and provide truthful, supportive information.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Deep tendon reflexes of +1

Rationale :

🔷 Preeclampsia commonly causes hyperreflexia, not decreased reflexes. Deep tendon reflexes of +1 indicate hyporeflexia, which is inconsistent with this condition.

🔷 Hyperreflexia occurs because preeclampsia increases central nervous system irritability, which may progress to seizures if untreated.

🔷 A reflex rating of +1 suggests reduced neuromuscular response and does not match the expected physiologic findings in preeclampsia.

🔷 Therefore, this finding does not align with the expected clinical picture and should prompt the nurse to reassess and consider other causes.

1+ pitting sacral edema

🔷 Edema—especially in dependent areas—is common in pregnancy and can be seen in preeclampsia.

🔷 This finding is not inconsistent with the diagnosis.

3+ protein in the urine

🔷 Proteinuria is a classic diagnostic feature of preeclampsia due to impaired kidney function.

🔷 A 3+ reading is consistent with preeclampsia.

Blood pressure 148/98 mm Hg

🔷 Elevated blood pressure (≥140/90) after 20 weeks’ gestation is one of the primary diagnostic criteria for preeclampsia.

🔷 This value aligns with the expected findings.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Participates in imaginary play

Rationale :

🔷 Imaginary (pretend) play is a hallmark developmental task of preschoolers, who engage in fantasy, role-playing, and creative storytelling.

🔷 This type of play helps develop social skills, emotional expression, problem-solving, and creativity.

🔷 Preschoolers commonly pretend to be superheroes, parents, teachers, or animals as part of normal cognitive and social development.

🔷 This behavior shows healthy imagination growth and aligns perfectly with the initiative vs. guilt stage of development.

Expresses need for privacy

🔷 The need for privacy typically emerges later, around school-age, when children become more modest and self-aware.

Controls impulsive feelings

🔷 Preschoolers are still learning impulse control; mastery of this skill doesn’t occur until school-age and even improves into adolescence.

Builds a collection of cards

🔷 Collecting items is more characteristic of school-age children, who enjoy categorizing, organizing, and trading objects.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

3 :
A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care?

4 :
A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

5 :
A nurse is reviewing the electronic fetal monitor strip for a client who is at 38 weeks of gestation and is in labor. Which of the following findings indicate to the nurse that the fetus is experiencing recurring late decelerations?

6 :
Which measure would the nurse include in the teaching plan for a client to reduce the risk for osteoporosis after menopause?

7 :
A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent?

8 :
A nurse is caring for a client who is pregnant and who has two children under the age of 4. The client reports "feeling overwhelmed lately." The client asks the nurse, "can't I have just one glass of wine here and there? Which of the following responses should the nurse make?

9 :
A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

10 :
A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse Include as being expected of a preschooler?

QLexNursing

3 : A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care?

4 : A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

5 : A nurse is reviewing the electronic fetal monitor strip for a client who is at 38 weeks of gestation and is in labor. Which of the following findings indicate to the nurse that the fetus is experiencing recurring late decelerations?

6 : Which measure would the nurse include in the teaching plan for a client to reduce the risk for osteoporosis after menopause?

7 : A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent?

8 : A nurse is caring for a client who is pregnant and who has two children under the age of 4. The client reports "feeling overwhelmed lately." The client asks the nurse, "can't I have just one glass of wine here and there? Which of the following responses should the nurse make?

9 : A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

10 : A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse Include as being expected of a preschooler?

3 :
A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care?

4 :
A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

5 :
A nurse is reviewing the electronic fetal monitor strip for a client who is at 38 weeks of gestation and is in labor. Which of the following findings indicate to the nurse that the fetus is experiencing recurring late decelerations?

6 :
Which measure would the nurse include in the teaching plan for a client to reduce the risk for osteoporosis after menopause?

7 :
A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent?

8 :
A nurse is caring for a client who is pregnant and who has two children under the age of 4. The client reports "feeling overwhelmed lately." The client asks the nurse, "can't I have just one glass of wine here and there? Which of the following responses should the nurse make?

9 :
A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

10 :
A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse Include as being expected of a preschooler?