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. When should a child receive the first dose of the hepatitis B virus (HBV) vaccine if the mother is hepatitis B surface antigen (HBsAg) negative?

• A. 2 months of age, before hospital discharge.
• B. Birth before discharge from the hospital.
• C. 6 months of age, at the third well-child visit.
• D. No time (this vaccine is not currently recommended).

Correct answer: B

Rationale: If the mother is HBsAg negative, it is recommended that the child receives the first dose of the hepatitis B vaccine at birth before discharge from the hospital. This is to provide early protection against the hepatitis B virus. The second dose of the vaccine is typically given at the first well-child visit, and the third dose is usually administered at a later date. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the Committee on Infectious Diseases of the American Academy of Pediatrics govern the recommendations for immunization, including the hepatitis B virus vaccine. Choice A is incorrect as the first dose should ideally be given at birth. Choice C is incorrect as waiting until 6 months of age may leave the child vulnerable to infection during the early months of life. Choice D is incorrect as the hepatitis B vaccine is recommended for all newborns, especially if the mother is HBsAg negative, to prevent transmission of the virus.

3. The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The child starts to cry and tells the nurse, "Do it later, okay?" What action should the nurse take?

• A. Postpone starting the IV until the next shift.
• B. Start the IV line and then allow for expression of feelings.
• C. Change the route of the antibiotics to PO.
• D. Postpone starting the IV line until the child is ready.

Correct answer: B

Rationale: Starting the IV as planned while allowing the child to express feelings afterward helps build trust and ensures the timely administration of necessary antibiotics. Delaying the procedure or changing the route could compromise the child's treatment.

4. What is a common significant side effect of opioid administration?

• A. Euphoria
• B. Diuresis
• C. Constipation
• D. Allergic reactions

Correct answer: C

Rationale: Constipation is one of the most common side effects of opioid administration due to the slowing down of gastrointestinal motility. Opioids affect the bowel movements, leading to constipation. Euphoria, while a possible effect, is less common than constipation. Diuresis is not a typical side effect of opioids; instead, urinary retention may occur. Allergic reactions are rare side effects of opioids, with symptoms such as rash, itching, or anaphylaxis.

5. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching?

• A. Keep baby powder out of reach.
• B. Inspect toys for removable parts.
• C. Allow the infant to take a bottle to bed.
• D. Teething biscuits can be used for teething discomfort.

Correct answer: A

Rationale: Baby powder can be inhaled by the infant and cause respiratory distress. Toys should be inspected to prevent choking hazards. Allowing an infant to take a bottle to bed can increase the risk of aspiration, and hard foods like teething biscuits should be given with caution.

Similar Questions