Nursing Elites

1. The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What should the nurse tell her?

• A. Fluids in addition to breast milk are not needed.
• B. Water should be given if the infant seems to nurse longer than usual.
• C. Clear juices are better than water to promote adequate fluid intake.
• D. Water once or twice a day will make up for losses resulting from environmental temperature.

Correct answer: A

Rationale: Breast milk provides adequate hydration, even in warm weather, so additional fluids like water are not necessary and can interfere with breastfeeding.

2. Which reflex is expected to disappear by 4 months of age?

• A. Rooting reflex
• B. Moro reflex
• C. Babinski reflex
• D. Palmar grasp

Correct answer: B

Rationale: The Moro reflex, also known as the startle reflex, typically disappears by 4 months as the infant's nervous system matures. This reflex is important for assessing the development of the nervous system in newborns. The Rooting reflex (Choice A) is related to turning the head in response to cheek stimulation; the Babinski reflex (Choice C) involves the fanning of toes in response to foot stimulation; and the Palmar grasp (Choice D) is the curling of the fingers around an object placed in the infant's hand. These reflexes have different timelines for disappearance and are not typically expected to be gone by 4 months of age.

3. What nursing consideration is most important when caring for a child with end-stage renal disease (ESRD)?

• A. Children with ESRD usually adapt well to minor inconveniences of treatment.
• B. Children with ESRD require extensive support until they outgrow the condition.
• C. Multiple stresses are placed on children with ESRD and their families until the illness is cured.
• D. Multiple stresses are placed on children with ESRD and their families because children's lives are maintained by drugs and artificial means.

Correct answer: D

Rationale: ESRD places significant stress on both the child and the family due to the ongoing need for dialysis, medications, and lifestyle restrictions, making it important for healthcare providers to offer extensive support and resources to manage these challenges.

4. The mother of a 6-month-old infant has returned to work and is expressing breast milk to be frozen. She asks for directions on how to safely thaw the breast milk in the microwave. What should the nurse recommend?

• A. Heat only 10 oz or more.
• B. Do not thaw or heat breast milk in a microwave oven.
• C. Always leave the bottle top uncovered to allow heat to escape.
• D. Shake the bottle vigorously for at least 30 seconds after heating.

Correct answer: B

Rationale: Thawing or heating breast milk in a microwave is not recommended because it can create hot spots that may burn the infant and destroy essential nutrients.

5. What type of dehydration occurs when the electrolyte deficit exceeds the water deficit?

• A. Isotonic dehydration
• B. Hypotonic dehydration
• C. Hypertonic dehydration
• D. Hyperosmotic dehydration

Correct answer: B

Rationale: Hypotonic dehydration occurs when the loss of electrolytes exceeds the loss of water, leading to a decrease in plasma osmolarity. This often occurs when sodium loss is greater than water loss, as in diarrhea or vomiting.

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