Question

Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?

Answer 1

Correct Answers:

Step

Rationale :

👶 The stepping reflex normally disappears by 2 months of age.

👶 Persistence of this reflex at 4 months may suggest neurological immaturity or dysfunction.

👶 While other reflexes like Babinski and plantar grasp may still be present at this age, stepping should have faded as voluntary motor control improves.

👶 The presence of this reflex would prompt the nurse to assess further or refer to a pediatric neurologist.

👶 Timely recognition of abnormal reflex persistence aids in early intervention for neurodevelopmental delays.

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Answer 2

Correct Answers:

The child is unable to push a toy lawnmower

Rationale :

🧸 By 24 months, children should demonstrate gross motor skills such as pushing or pulling toys while walking.

🧸 Not being able to push a toy lawnmower suggests delayed large muscle coordination.

🧸 Difficulty with fine motor skills like unscrewing a lid is not expected until age 3.

🧸 Falling when bending over can be normal in toddlers, but inability to walk while pushing is more significant.

🧸 Gross motor delays can indicate underlying neuromuscular concerns and may require referral for early intervention.

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Answer 3

Correct Answers:

"The fever is causing an increase in your baby's heart rate."

Rationale :

🔥 Fever increases metabolic rate and cardiac output, which raises the heart rate in infants.

🔥 A HR of 190 bpm in a 2-month-old is elevated but can be explained by a high fever (104°F).

🔥 This is called febrile tachycardia, a common and expected physiologic response.

🔥 Other options suggest misinterpretations or downplay the need for accurate education.

🔥 The nurse should also monitor hydration, comfort, and antipyretic effectiveness.

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Answer 4

Correct Answers:

Tugging on the affected ear lobe

Rationale :

👂 Tugging or pulling at the ear is a common behavioral sign in young children with otitis media, as they cannot verbalize ear pain.

👂 The infection causes pressure and inflammation behind the tympanic membrane, leading to discomfort.

👂 Clear drainage is not typical unless tympanic rupture occurs.

👂 Pain with manipulation suggests otitis externa, not media.

👂 Erythema may be present on the tympanic membrane, not external ear.

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Answer 5

Correct Answers:

0.96

Rationale :

💉 Order: 3 mg/kg × 20 kg = 60 mg.

💉 Available: 125 mg / 2 mL = 62.5 mg/mL.

💉 Calculation: 60 mg ÷ 62.5 mg/mL = 0.96 mL.

💉 This ensures the child receives the accurate therapeutic dose based on weight.

💉 Always round per protocol and administer using a syringe for precision.

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Answer 6

Correct Answers:

The mother supplements feedings with water
The mother carefully washes her breasts prior to feeding the infant

Rationale :

✅ B. The mother supplements feedings with water

🍼 Exclusively breastfed infants do not require supplemental water, even in hot climates.

🍼 Breast milk is made up of approximately 87% water, providing sufficient hydration.

🍼 Giving water can lead to early satiety, reducing milk intake and caloric consumption, which may contribute to poor weight gain.

🍼 Excess water can also increase the risk of hyponatremia, a dangerous drop in sodium levels.

🍼 The AAP and WHO recommend exclusive breastfeeding for the first 6 months without any other liquids unless medically indicated.

✅ E. The mother carefully washes her breasts prior to feeding the infant

🍼 Washing breasts before every feed is not recommended and may remove natural oils that protect the nipples and infant’s mouth.

🍼 These oils help maintain skin integrity and prevent dryness or cracking.

🍼 Over-washing may also introduce harsh soaps or irritants, potentially leading to skin irritation or mastitis.

🍼 Normal hygiene, such as daily bathing, is adequate for breastfeeding mothers.

🍼 Education should emphasize comfort, proper latch, and skin-to-skin bonding, not excessive cleansing.

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Answer 7

Correct Answers:

Notify the provider of the situation

Rationale :

🧑‍⚕️ At 17, the patient is a mature minor, and their autonomy and wishes must be respected—especially in end-of-life or serious care situations.

🧑‍⚕️ The provider must be informed to evaluate legal and ethical responsibilities in this case.

🧑‍⚕️ Administering treatment without consent (sedative or IV) violates patient rights and ethical practice.

🧑‍⚕️ Open discussion should follow, involving ethics consultation if needed.

🧑‍⚕️ The nurse's role is to advocate and communicate, not override decisions.

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Answer 8

Correct Answers:

Lack of social and emotional readiness for school

Rationale :

🏫 Children raised by non-parental caregivers, especially in contexts of maternal mental illness or substance use, are at risk for emotional delays.

🏫 While speech or fine motor skills may remain intact, social-emotional development can be impacted by attachment disruption or trauma.

🏫 This may affect peer interaction, emotional regulation, and adaptability in school.

🏫 Early intervention or evaluation by child psychology or social work is appropriate.

🏫 The nurse should focus on supporting whole-child readiness, not just academics.

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Answer 9

Correct Answers:

The teacher says my child has to squint to see the board?'

Rationale :

👁️ Squinting is a sign of refractive error like myopia or astigmatism.

👁️ Uncorrected vision issues can impact learning, attention, and social engagement.

👁️ Early identification through vision screening is critical to prevent long-term visual impairment.

👁️ Other behaviors (bossiness, cheating) are developmentally normal at age 6.

👁️ Referral to an optometrist or ophthalmologist is warranted.

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Answer 10

Correct Answers:

3

Rationale :

🍶 Ordered: 375 mg; Supply: 125 mg/5 mL = 25 mg/mL.

🍶 To give 375 mg: 375 mg ÷ 125 mg × 5 mL = 15 mL.

🍶 1 teaspoon = 5 mL, so: 15 mL = 3 teaspoons.

🍶 Nurse should educate parents using familiar units (teaspoons) for home care.

🍶 Accurate dose delivery is critical to treatment effectiveness and avoiding resistance.

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QLexNursing

1 :
Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?

2 :
The nurse is observing a 24-month-old boy in a daycare center. Which finding suggests delayed motor development?

3 :
A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 1901min and his temperature is 400 C (1040 F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate

4 :
A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?

5 :
The order is Solumedrol 3 mg/kg for a child weighing 20 kg. Solumedrol is available as 125 mg/2mL. How many ml(s) must the nurse administer?

6 :
A new mother tells the nurse that she is having difficulty breastfeeding her baby. When observing the mother, which actions prompt the nurse to provide teaching about proper breastfeeding techniques? Select all that apply.

7 :
A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take?

9 :
A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?

10 :
Ceclor oral suspension 375 mg g. 8h, is ordered for a patient on discharge. The pharmacy gives the patient Ceclor 125 mg/5 ml oral suspension. How many teaspoons will the nurse instruct the patient to take per dose? Record numbers only.

QLexNursing

1 : Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?

2 : The nurse is observing a 24-month-old boy in a daycare center. Which finding suggests delayed motor development?

3 : A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 1901min and his temperature is 400 C (1040 F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate

4 : A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?

5 : The order is Solumedrol 3 mg/kg for a child weighing 20 kg. Solumedrol is available as 125 mg/2mL. How many ml(s) must the nurse administer?

6 : A new mother tells the nurse that she is having difficulty breastfeeding her baby. When observing the mother, which actions prompt the nurse to provide teaching about proper breastfeeding techniques? Select all that apply.

7 : A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take?

9 : A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?

10 : Ceclor oral suspension 375 mg g. 8h, is ordered for a patient on discharge. The pharmacy gives the patient Ceclor 125 mg/5 ml oral suspension. How many teaspoons will the nurse instruct the patient to take per dose? Record numbers only.

1 :
Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?

2 :
The nurse is observing a 24-month-old boy in a daycare center. Which finding suggests delayed motor development?

3 :
A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 1901min and his temperature is 400 C (1040 F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate

4 :
A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?

5 :
The order is Solumedrol 3 mg/kg for a child weighing 20 kg. Solumedrol is available as 125 mg/2mL. How many ml(s) must the nurse administer?

6 :
A new mother tells the nurse that she is having difficulty breastfeeding her baby. When observing the mother, which actions prompt the nurse to provide teaching about proper breastfeeding techniques? Select all that apply.

7 :
A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take?

9 :
A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?

10 :
Ceclor oral suspension 375 mg g. 8h, is ordered for a patient on discharge. The pharmacy gives the patient Ceclor 125 mg/5 ml oral suspension. How many teaspoons will the nurse instruct the patient to take per dose? Record numbers only.