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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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View Related questions

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.

Correct Answer is A

Explanation

Choice A rationale

Negative behaviors characterized by the need for autonomy are typical of toddlers. According to Erikson, this stage is known as autonomy versus shame and doubt, where toddlers

assert their independence and develop self-control.

Choice B rationale

Erikson's stage of initiative versus guilt applies to preschool children, not toddlers. This stage involves children beginning to assert power and control over their environment through

directing play and other social interactions.

Choice C rationale

The need to start a task and complete it is associated with Erikson's stage of industry versus inferiority, which applies to school-aged children, not toddlers. This stage involves

developing a sense of pride in their accomplishments.

Choice D rationale

The discovery of their identity is a characteristic of Erikson's stage of identity versus role confusion, which pertains to adolescence. During this stage, teenagers work on refining a

sense of self.

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