In terms of gross motor development, which should the nurse expect a 5-month-old infant to do? (Select all that apply.)

Correct Answer: A

Rationale: At 5 months old, an infant would typically be able to roll from abdomen to back (Choice A). This is an important gross motor skill that develops during this stage. Additionally, putting their feet in their mouth when lying on their back (Choice B) is also a common movement seen at this age. Both these actions demonstrate the increasing strength and coordination of the infant's muscles as they develop and explore their physical abilities. Rolling from back to abdomen (Choice C) and sitting erect without support (Choice D) typically develop later, around 6-7 months and 8-9 months, respectively. Moving from prone to sitting position (Choice E) and adjusting posture to reach an object (Choice F) are usually mastered around 8-9 months as well.

Correct Answer: C

Rationale: The best nursing action in this scenario is to explain why a Band-Aid is not needed. At 5 years old, Samantha is at an age where she can begin to understand explanations. By providing her with a simple and clear explanation, the nurse can help Samantha understand that a Band-Aid is not necessary in this situation. This also promotes education and helps Samantha learn about wound healing and appropriate care. It is important to involve the child in the decision-making process and provide education to foster their understanding of their own health.

Correct Answer: C

Rationale: The nurse should be most concerned about the child's self-esteem and sense of competence. A 12-year-old male with short stature due to a constitutional growth delay may experience feelings of inadequacy or embarrassment because of his height. It is important for the nurse to address these emotional aspects of the condition and support the child in developing a positive self-image. By promoting the child's self-esteem and sense of competence, the nurse can help the child navigate any challenges associated with his height and build confidence in his abilities and worth as an individual.

Correct Answer: C

Rationale: An important consideration when the nurse is discussing enuresis with the parents of a young child is that organic causes related to enuresis should be considered first. Enuresis, or bedwetting, can have various causes including physical issues like urinary tract infections, constipation, or structural abnormalities. It is essential to rule out any underlying medical conditions before addressing behavioral or psychological factors. By focusing on organic causes first, healthcare providers can ensure that the child receives appropriate evaluation and treatment, leading to better outcomes.

Correct Answer: A

Rationale: In a school-age child with urosepsis, the nurse should expect the assessment finding of fever with a positive blood culture. Urosepsis is a severe infection in the urinary tract that has spread to the bloodstream, causing systemic symptoms such as fever. Positive blood cultures indicate the presence of bacteria in the bloodstream, confirming the diagnosis of sepsis. Other common symptoms of urosepsis may include chills, rapid heart rate, increased respiratory rate, and altered mental status. Proteinuria and edema (choice B) are more indicative of kidney disorders such as nephrotic syndrome rather than urosepsis. Oliguria and hypertension (choice C) may be seen in conditions like acute kidney injury but are not specific to urosepsis. Anemia and thrombocytopenia (choice D) are more characteristic of conditions such as hemolytic uremic syndrome rather than urosepsis.