The nurse would assess respirations in a 9-month-old infant when the client is:
Playing in the playroom.
Crying.
Sleeping.
Laughing.
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 A
Explanation
Choice A rationale
Toddlers are at a stage where they are increasingly curious and mobile, which requires close supervision to ensure their safety. They are also prone to tantrums as they test
boundaries and express frustration due to limited communication skills. Effective management of tantrums and supervision can help parents guide their child's behavior and ensure
their safety.
Choice B rationale
Solitary play and identity development are more characteristic of older children. Toddlers engage more in parallel play, where they play alongside other children but not directly with
them. Encouraging solitary play is not as developmentally appropriate for toddlers.
Choice C rationale
Establishing trust is crucial in infancy when infants learn to trust their caregivers to meet their needs. Dental care should start around the toddler years, but the primary focus should
be on supervision and behavior management rather than dental care initiation.
Choice D rationale
Establishing relationships and developing self-confidence are vital across all developmental stages, but in toddlers, the priority lies in providing a safe environment and guiding
behavior through supervision and tantrum management.
Correct Answer is B
Explanation
Choice A rationale
Vitamin K has no role in stabilizing blood glucose levels; hypoglycemia in newborns is managed differently.
Choice B rationale
Vitamin K is essential for blood clotting, and newborns typically have low stores at birth, necessitating supplementation to prevent bleeding disorders.
Choice C rationale
There is no established link between maternal fever and the need for vitamin K; prophylaxis is standard for all newborns regardless of maternal health.
Choice D rationale
Newborns do not have sufficient prothrombin or other clotting factors, which is why vitamin K administration is critical.