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The nurse would assess respirations in a 9-month-old infant when the client is:

A.

Playing in the playroom.

B.

Crying.

C.

Sleeping.

D.

Laughing.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Playing might cause irregular breathing patterns due to excitement or activity, making it hard to get an accurate respiratory rate.

 

Choice B rationale

Crying can alter the normal breathing rate and pattern, resulting in an inaccurate assessment of respirations.

 

Choice C rationale

Sleeping provides the most accurate assessment of respirations, as the infant’s breathing will be at its natural, resting rate.

 

Choice D rationale

Laughing, similar to crying, causes irregular breathing patterns due to physical exertion and emotions, affecting accuracy.


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Correct Answer is B

Explanation

Choice A rationale

Placing a baby’s crib next to a heater can pose a risk of overheating or burns. Newborns should be kept at a safe distance from heaters to prevent accidents.

Choice B rationale

Removing extra blankets from the crib is recommended to reduce the risk of suffocation and sudden infant death syndrome (SIDS). This choice reflects an understanding of crib safety.

Choice C rationale

Padding the mattress can pose suffocation risks and is not recommended. A firm mattress without any padding is the safest option for newborns.

Choice D rationale

Placing a baby on their stomach to sleep increases the risk of SIDS. The recommended sleeping position for newborns is on their back, as this significantly reduces the risk.

Correct Answer is D

Explanation

Choice A rationale

Examining the tympanic membrane at the beginning may cause distress to the child and make the rest of the exam difficult.

Choice B rationale

Before auscultating the chest and abdomen, the child needs to be calm and cooperative, which might not be the case if their ear is examined first.

Choice C rationale

Examining the tympanic membrane before the head and neck could lead to increased anxiety and uncooperativeness in the child during the rest of the exam.

Choice D rationale

Examining the tympanic membrane at the end allows for a more accurate and complete examination without causing the child to become distressed early in the process.

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