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:

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Pediatric Nursing Study Guide Questions

Question 1 of 5

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: The correct answer is A because the ability to hold a rattle when placed in the infant's hands, but not yet being able to voluntarily grasp it, is a sign of normal development for a 3-month-old. It indicates progress in motor skills and is within the expected range for this age group.

Question 2 of 5

Acute laryngotracheobronchitis is associated with which radiological sign?

Correct Answer: C

Rationale: The steeple sign is a characteristic radiologic feature of croup (acute laryngotracheobronchitis).

Question 3 of 5

After days of phototherapy, the bilirubin level of the patient in Question 5 declines below mg/dL One day off phototherapy, the level of bilirubin remains less than mg/dL The patient is discharged home and grows well while breast-feeding At month of age, he returns with significant pallor, tachycardia, and a new heart murmur The most likely problem at this time is

Correct Answer: B

Rationale: Ductal-dependent congenital heart disease may manifest after ductus arteriosus closure

Question 4 of 5

A head-injured 4-year-old patient, who opens eyes to painful stimulus, is confused, and withdraws from pain. His Glasgow coma score is:

Correct Answer: B

Rationale: Glasgow Coma Score is calculated as Eye Opening (2) + Verbal Response (4) + Motor Response (4) = 10, indicating moderate head injury.

Question 5 of 5

Which is not a common cause of adverse food reactions?

Correct Answer: B

Rationale: Food aversion is a psychological reaction, not a common cause of adverse food reactions.

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