An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action?

Correct Answer: C

Rationale: The most appropriate nursing action when an 8-year-old girl asks how the blood pressure apparatus works is to explain in simple terms how it works. Children are curious by nature and providing a simple explanation in a language they can understand helps satisfy their curiosity and also promotes their understanding. By explaining how the blood pressure apparatus works, the nurse can educate the child about a common medical device and reduce any anxiety or fear the child may have about it. This approach encourages the child to feel more comfortable and engaged in their healthcare experience.

Correct Answer: C

Rationale: A ventricular septal defect (VSD) is a congenital heart defect characterized by a hole in the septum that separates the heart's two lower chambers (ventricles). When assessing a child with an unrepaired VSD, the nurse would expect to hear a murmur. The murmur is typically described as a harsh, holosystolic (pansystolic) murmur, best heard at the left lower sternal border. This murmur occurs due to the turbulent blood flow across the defect during systole. It is important for the nurse to recognize this characteristic murmur associated with a VSD to facilitate appropriate management and follow-up care for the child.

Correct Answer: D

Rationale: The correct knowledge that the nurse's response should be based on is that it is acceptable to encourage head control and turning over. At 3 months of age, encouraging the infant to be prone while awake can help promote the development of head control, neck strength, and eventually facilitate the ability to turn over. This practice is considered safe and beneficial for infants within the appropriate age range, as long as the infant is supervised during the awake period. It is important to promote safe sleep practices for infants to reduce the risk of Sudden Infant Death Syndrome (SIDS), but allowing supervised tummy time for an awake infant is beneficial for their motor development.

Correct Answer: A

Rationale: The nurse should recommend never heating a bottle in a microwave oven. Microwaves do not heat liquids evenly, and there is a risk of creating hot spots in the formula, which can burn the baby's mouth and throat. It is safer to heat the formula by placing the bottle in warm water or using a bottle warmer to ensure uniform heating throughout.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.