By the age of 7 months, the infant is able to do all the following EXCEPT

Correct Answer: D

Rationale: Rolling over is usually achieved earlier, by 4-6 months, while other skills are typical for 7 months.

Correct Answer: A

Rationale: The most common cause of anemia in preterm newborns is frequent blood sampling. Preterm infants are often subject to numerous blood tests for various reasons such as monitoring oxygen and blood gas levels, assessing bilirubin levels, infection screening, and more. These repeated blood withdrawals lead to a loss of red blood cells and can contribute to the development of anemia in preterm infants. Anemia in preterm newborns can have significant consequences, including impaired growth and development, delayed hospital discharge, and the potential need for blood transfusions. Therefore, minimizing unnecessary blood sampling and utilizing non-invasive monitoring methods whenever possible are key strategies in preventing and managing anemia in preterm newborns.

Correct Answer: B

Rationale: Opening the patient's jaw and inserting a mouth gag is not part of the appropriate nursing care for a patient experiencing a convulsive seizure. Doing so can potentially harm the patient by causing injury to the teeth, jaw, or airway. It is important to protect the patient's airway during a seizure, but this can be done by positioning the patient on their side with the head flexed forward, ensuring a clear airway without the need for a mouth gag.

Correct Answer: C

Rationale: During the surgical procedure, the circulating nurse, scrub nurse, and nurse first assistant are responsible for keeping track of all instruments, needles, and sponges used. As the surgical incision is being closed, the circulating nurse and the scrub nurse/nurse first assistant conduct a final count of all needles, sponges, and instruments to ensure that nothing is accidentally left inside the patient's body. This is a critical step in preventing retained surgical items (RSI), which can lead to serious complications for the patient. It is part of the standard protocol in the operating room to have these specific personnel take charge of counting and verifying all items before the procedure is concluded.

Correct Answer: C

Rationale: The nurse would first assess for an irregular heart rate and rhythm. In a 4-month old infant with a congenital heart defect experiencing marked dyspnea at rest, the sudden onset of cyanosis (blue coloration) and increased respiratory rate can indicate worsening heart failure and potential arrhythmias. Assessing for any abnormal heart rhythms is a priority to determine if immediate intervention is required to stabilize the infant's condition and prevent further deterioration.