A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as:

Correct Answer: A

Rationale: In this scenario, the correct interpretation by the nurse is option A) normal development. At 3 months of age, it is typical for infants to have reflexive grasping behaviors but not yet demonstrate voluntary grasping. This indicates that the infant is on track developmentally. Option B) significant developmental lag is incorrect because the infant's behavior is within the expected range for their age. Option C) slightly delayed development due to prematurity is also incorrect as prematurity can impact developmental milestones, but this particular behavior is not concerning. Option D) suggestive of a neurologic disorder such as cerebral palsy is not supported by the information given as the infant is displaying age-appropriate behavior. Educationally, it is crucial for nurses and healthcare providers to have a clear understanding of normal developmental milestones in pediatric patients. By recognizing typical behaviors, they can identify deviations from the norm early and intervene appropriately. This knowledge helps in providing proactive care and support to promote healthy growth and development in infants.

Correct Answer: C

Rationale: In pediatric nursing, fluoride supplementation is a crucial topic due to its impact on dental health. The correct answer, option C, is that Sarah may need to begin taking fluoride supplements at age 6 months. This is because breast milk is low in fluoride, and after 6 months, the fluoride stores from birth start to deplete. Introducing fluoride supplements at this age helps in the development of strong teeth. Option A is incorrect because starting fluoride supplements at 2 weeks old is unnecessary and could lead to excessive fluoride intake. Option B is incorrect because relying solely on fluoridated water may not provide adequate fluoride levels for dental health. Option D is also incorrect as the American Academy of Pediatrics recommends starting fluoride supplements at 6 months for exclusively breast-fed infants. Educationally, it's important to understand the rationale behind fluoride supplementation in infants to promote optimal dental health. Nurses must provide accurate information to parents to prevent dental problems while avoiding potential risks of excessive fluoride intake at a young age. This knowledge equips healthcare professionals to support families in making informed decisions regarding their child's health.

Correct Answer: B

Rationale: In assessing adolescent drug abuse seriousness, the factor that takes +2 in the score is the use of hallucinogens (Option B). This is because hallucinogens are psychoactive substances that can lead to severe distortions in perception, thought, and mood. Adolescents using hallucinogens are at higher risk of experiencing dangerous or harmful effects on their physical and mental health compared to those using other types of drugs. Option A (female sex) is incorrect because gender alone is not a definitive indicator of the seriousness of drug abuse in adolescents. Both males and females can be equally affected by drug abuse. Option C (positive family history of drug abuse) is also significant but does not specifically address the immediate risk posed by the use of hallucinogens. While a family history of drug abuse can increase the likelihood of substance abuse in adolescents, it does not directly relate to the severity of drug abuse in this context. Option D (use before driving) is important in terms of safety and legal implications but does not directly reflect the severity of drug abuse. It focuses more on the behavior associated with drug use rather than the type of drug being used. In an educational context, understanding the specific risks associated with different types of drugs is crucial for healthcare professionals working with adolescents. By recognizing the increased seriousness of hallucinogen use, nurses can better assess and intervene in cases of adolescent drug abuse to provide appropriate care and support. This knowledge can help in developing targeted interventions and prevention strategies to address substance abuse issues effectively.

Correct Answer: C

Rationale: Primary amenorrhea is the absence of menstruation by age 15 in the presence of normal growth and secondary sexual characteristics, or the absence of menstruation by age 13 with the absence of secondary sexual characteristics. In the context of pediatric nursing, the correct answer is C) 3 years from the onset of puberty. This is because primary amenorrhea requires evaluation if menstruation does not occur within this timeframe after the onset of puberty, which is typically around age 12. Option A) 1 year from the onset of puberty is too short of a timeframe to definitively diagnose primary amenorrhea as it may take longer for some individuals to establish regular menstrual cycles. Option B) 2 years from the onset of puberty is also premature for evaluation as it does not allow enough time for the menstrual cycle to regulate. Option D) 4 years from the onset of puberty is too long of a period to wait for evaluation as early intervention and diagnosis are crucial in addressing any underlying causes of primary amenorrhea in pediatric patients. Understanding the timeline for evaluating primary amenorrhea is essential for pediatric nurses to identify and address any potential reproductive health issues early on. By knowing when to intervene and refer patients for further evaluation, nurses can provide comprehensive care and support for adolescents experiencing menstrual irregularities.

Correct Answer: B

Rationale: In mechanical ventilation, providing adequate Positive End-Expiratory Pressure (PEEP) can mainly reduce barotrauma. Barotrauma occurs when there is damage to the lung tissue due to high pressures during mechanical ventilation. By applying PEEP, the alveoli remain open at the end of expiration, preventing lung collapse and reducing the need for high peak pressures, hence decreasing the risk of barotrauma. Option A) Volutrauma is excessive stretch and overdistension of the alveoli, which is more related to high tidal volumes rather than PEEP. Adequate PEEP actually helps prevent volutrauma by recruiting collapsed alveoli. Option C) Oxytrauma is damage caused by high levels of oxygen exposure over time. While PEEP may reduce the need for high FiO2 levels, it is not primarily aimed at reducing oxytrauma. Option D) Pneumonia is an infection of the lung tissue and is not directly related to the application of PEEP in mechanical ventilation. Understanding the effects of PEEP on the respiratory system in pediatric patients is crucial for nurses caring for critically ill children on mechanical ventilation. Proper application of PEEP can improve oxygenation, prevent lung injury, and optimize respiratory function in pediatric patients requiring ventilatory support.