A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?

Correct Answer: C

Rationale: At 6 months, infants are generally ready to start eating iron-fortified cereals as their iron stores begin to deplete. Introducing iron-fortified cereals at this age helps meet the infant's nutritional needs, particularly for iron, which becomes deficient as the infant's iron reserves diminish. It is a safe and appropriate first food to introduce to infants around 6 months of age, along with continued breastfeeding or formula feeding.

Correct Answer: A

Rationale: In a tetralogy of Fallot situation, placing the infant in a knee-chest position is the initial priority to help increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation. This position can assist in optimizing oxygen levels before considering other interventions.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Respiratory rate of 76 breaths/minute. The highest priority assessment finding in a 2-hour-old infant born by cesarean delivery is their respiratory status. Infants, especially those born via cesarean section, are at risk for respiratory distress syndrome due to incomplete lung development. A respiratory rate of 76 breaths/minute could indicate respiratory distress, which requires immediate intervention to ensure adequate oxygenation. Option A, blood pressure of 76/42 mmHg, is not as critical in this immediate postnatal period as respiratory status. Infants typically have lower blood pressure values compared to adults. Faint heart murmur (option B) is common in newborns and not necessarily a cause for concern at this stage. Option D, blood glucose of 45 mg/dl, is also important but not as urgent as addressing potential respiratory distress in a newborn. In an educational context, understanding the priorities in assessing a newborn's health is crucial for healthcare providers working in maternity care. This question highlights the significance of recognizing and managing respiratory distress promptly in newborns, emphasizing the need for quick and accurate assessment to ensure the well-being of the infant.

Correct Answer: D

Rationale: In this scenario, the correct action for the school nurse to take is D) Schedule a test for Lyme disease if a rash appears. This is the most appropriate response because tick bites can potentially transmit Lyme disease, which is caused by the bacterium Borrelia burgdorferi. By scheduling a test for Lyme disease if a rash appears, the nurse is following best practice guidelines to ensure early detection and treatment if necessary. Option A) Refer the mother to the Centers for Disease Control and Prevention is not the most immediate or practical step to take in this situation. The school nurse should first assess the child's symptoms and provide appropriate care before considering external referrals. Option B) Report the incident to the school principal is not the most urgent action needed. While it is important to document incidents, the immediate concern is the child's health and potential risk of Lyme disease. Option C) Culture the bite site when the child returns to school is not a recommended course of action. Lyme disease testing involves blood tests, not culturing the bite site, and waiting for the child to return to school may delay necessary testing and treatment. In an educational context, it is crucial for school nurses to be knowledgeable about common health risks, like tick bites and Lyme disease, especially in areas where these are prevalent. Prompt and appropriate actions can help prevent complications and ensure the well-being of students under their care. It is essential for school nurses to stay updated on best practices for managing various health concerns that may arise in a school setting.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Numbness and inability to move fingers. When a cast is applied and elevated above the level of the heart during the drying process, there is a risk of compartment syndrome developing. Compartment syndrome occurs when there is increased pressure within a muscle compartment, leading to decreased blood flow and potential nerve damage. Numbness and the inability to move fingers are indicative of nerve compression and impaired circulation, which are serious complications requiring immediate attention to prevent permanent damage. Option A) Itching sensation under the cast is a common sensation due to the drying process and is not typically a cause for immediate concern. Option B) Swelling of fingers with brisk capillary refill is a normal response to the elevation of the cast and should resolve once the cast is fully dried and the limb is lowered. Option D) Visible bruising above the cast may indicate minor trauma during the application of the cast but is not a critical finding that requires immediate reporting. Educationally, it is important for healthcare providers to understand the signs and symptoms of compartment syndrome to prevent complications such as tissue necrosis and permanent nerve damage. Prompt recognition and intervention are crucial in managing this condition effectively and ensuring optimal patient outcomes.