During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action?

Correct Answer: C

Rationale: Significant head lag in an 8-month-old infant can be a concerning sign indicating potential developmental delays or muscle weakness. The most appropriate action for the nurse in this situation is to refer the child for further evaluation by a healthcare provider, such as a pediatrician or developmental specialist, to assess and address the underlying cause of the head lag. It is important to rule out any potential developmental issues early on to provide the necessary interventions and support for the infant's optimal growth and development.

Correct Answer: B

Rationale: Rheumatic fever is an inflammatory disease that can develop as a complication of untreated or inadequately treated infections caused by group A beta-hemolytic streptococci. These bacterial infections are usually in the form of strep throat or scarlet fever. Rheumatic fever typically occurs 2-4 weeks after a streptococcal infection. The body's immune response to the streptococcal infection can lead to an autoimmune reaction, resulting in rheumatic fever. It is important to promptly diagnose and treat streptococcal infections to prevent the development of rheumatic fever.

Correct Answer: C

Rationale: Total parenteral nutrition (TPN) is a method of providing nutrition intravenously to individuals who are unable to obtain adequate nutrition through oral or enteral routes. The components of a TPN solution typically include dextrose (a source of carbohydrates for energy), amino acids (building blocks of proteins), electrolytes (such as sodium, potassium, and magnesium to maintain proper balance), vitamins, and trace elements (such as zinc and selenium). Trace minerals are essential for various metabolic functions in the body, and their inclusion in TPN solutions is crucial to prevent deficiencies. Therefore, trace minerals are likely to be present in TPN solutions, making them an essential component, unlike the other options provided in the question.

Correct Answer: A

Rationale: In the scenario described, the baby is born with temporary immunity to diseases that the mother is immune to. This is an example of naturally acquired passive immunity, where the baby receives preformed antibodies from the mother, providing immediate protection against certain diseases. This type of immunity is passive because the baby did not produce the antibodies themselves, and it is naturally acquired as it occurs through the transfer of antibodies from the mother to the baby during pregnancy.

Correct Answer: C

Rationale: A complete blood count (CBC) is a common blood test that provides important information about the types and numbers of cells in the blood, such as red blood cells, white blood cells, and platelets. The primary purpose of performing a CBC before surgery is to identify any abnormalities in the blood that could affect the patient's ability to undergo the surgical procedure safely. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels indicated by a CBC may suggest anemia, which could impact the patient's ability to tolerate surgery and anesthesia. Anemia can result in decreased oxygen delivery to tissues and organs, leading to potential complications during surgery. Therefore, identifying low HCT and Hb levels through a CBC allows healthcare providers to take appropriate measures to address and manage the condition before proceeding with surgery.