A mother brings her 3-month-old infant to the clinic, concerned about frequent vomiting after feeding. The practical nurse (PN) suspects gastroesophageal reflux (GER). Which recommendation should the PN provide to the mother?

Correct Answer: C

Rationale: The correct recommendation for reducing symptoms of gastroesophageal reflux (GER) in infants is to keep the infant upright for 30 minutes after feeding. This position helps prevent the backflow of stomach contents, alleviating symptoms of reflux. Placing the infant in a prone position or providing larger, less frequent feedings may worsen symptoms, while offering only formula thickened with rice cereal is not the first-line intervention for GER.

Correct Answer: B

Rationale: Administering the scheduled dose is appropriate in this scenario as the heart rate of 128 bpm falls within the acceptable range for a two-year-old child with heart failure. It indicates that the child may benefit from the therapeutic effects of digoxin. Monitoring the heart rate closely after administration is essential to ensure the medication's effectiveness and safety.

Correct Answer: C

Rationale: Weighing the child daily is crucial in managing a child with acute glomerulonephritis as it helps in monitoring fluid retention, which is a key concern in this condition. Daily weight monitoring allows healthcare providers to assess changes in fluid status and adjust treatment accordingly. It is an essential component of the care plan to ensure the child's health status is closely monitored during the management of acute glomerulonephritis.

Correct Answer: D

Rationale: In this scenario, option D, "Demonstrates startle reflex," requires further evaluation by the nurse when assessing a 6-month-old infant. The startle reflex, also known as the Moro reflex, is typically present in newborns but should diminish or disappear by 3-4 months of age. Its persistence at 6 months could indicate a developmental delay or neurological issue that warrants further investigation by the nurse and healthcare team. Option A, "Has doubled birth weight," is a normal developmental milestone for a 6-month-old infant, indicating appropriate growth and nutrition. Option B, "Turn head to locate sound," is a typical auditory milestone for a 6-month-old infant, demonstrating developing sensory abilities. Option C, "Plays peek-a-boo," is a social and cognitive milestone that is expected around 6-8 months of age, showing engagement and interaction with the environment. In a pediatric nursing context, understanding developmental milestones is crucial for early identification of any delays or abnormalities. Nurses need to assess infants holistically to ensure they are meeting these milestones, as deviations can indicate underlying health issues or developmental concerns that require prompt intervention. Regular assessments help nurses provide appropriate care and support to promote optimal growth and development in pediatric patients.

Correct Answer: C

Rationale: In pediatric nursing, selecting appropriate toys for children with specific conditions or needs is crucial for promoting their well-being and aiding in their development. In the case of a 3-year-old child in a spica cast following a motor vehicle collision, the best toy option is a set of cloth and hand puppets (Option C). The rationale behind choosing hand puppets is that they allow for imaginative play and interaction, which can be beneficial for a child confined to a spica cast. Hand puppets can engage the child's attention, provide a means for self-expression, and facilitate social interaction even in limited physical conditions. Option A (Duck that squeaks) may not offer the same level of interaction and creative play as hand puppets. Option B (Fashion doll and clothes) might be challenging for a child in a spica cast to manipulate due to physical restrictions. Option D (Handheld video game) may not promote the same level of social interaction and creative engagement as hand puppets do. By choosing the hand puppets, the nurse can support the child's emotional well-being, cognitive development, and social skills even during a challenging time of physical confinement. This educational rationale underscores the importance of selecting toys that not only entertain but also support the holistic development of pediatric patients in various healthcare settings.