The nurse is assessing a 6 month old infant. Which response requires further evaluation by the nurse?

Correct Answer: D

Rationale: In this scenario, option D, "Demonstrates startle reflex," requires further evaluation by the nurse when assessing a 6-month-old infant. The startle reflex, also known as the Moro reflex, is typically present in newborns but should diminish or disappear by 3-4 months of age. Its persistence at 6 months could indicate a developmental delay or neurological issue that warrants further investigation by the nurse and healthcare team. Option A, "Has doubled birth weight," is a normal developmental milestone for a 6-month-old infant, indicating appropriate growth and nutrition. Option B, "Turn head to locate sound," is a typical auditory milestone for a 6-month-old infant, demonstrating developing sensory abilities. Option C, "Plays peek-a-boo," is a social and cognitive milestone that is expected around 6-8 months of age, showing engagement and interaction with the environment. In a pediatric nursing context, understanding developmental milestones is crucial for early identification of any delays or abnormalities. Nurses need to assess infants holistically to ensure they are meeting these milestones, as deviations can indicate underlying health issues or developmental concerns that require prompt intervention. Regular assessments help nurses provide appropriate care and support to promote optimal growth and development in pediatric patients.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Object permanence. Object permanence is a crucial developmental milestone in infants where they understand that objects continue to exist even when they are out of sight. When the nurse hides the block under the baby's blanket and the baby actively looks for it, it demonstrates the baby's developing sense of object permanence. Option A) Separation anxiety is incorrect because it refers to a child's fear of being separated from their caregiver, which is usually seen around 6-8 months of age. Option B) Associative play involves children playing alongside each other but not necessarily interacting with each other in a coordinated manner, which is more common in older toddlers and preschoolers. Option C) Object prehension involves the ability to grasp and hold onto objects, which is an earlier milestone typically seen in infants around 6-9 months of age. Understanding these developmental milestones is essential for pediatric nurses as it helps in assessing a child's growth and development, identifying any potential delays or concerns, and providing appropriate support and interventions to promote healthy development.

Correct Answer: C

Rationale: Surgical repairs for hypospadias are typically recommended to be performed before the child is potty trained. This timing helps in avoiding complications, ensures better outcomes, and makes the surgical process smoother. Early correction also minimizes the psychological impact on the child regarding genital differences and can improve long-term psychological well-being.

Correct Answer: A

Rationale: To calculate the dose for each administration, multiply the child's weight (25 kg) by the dose (300 mg/kg/24 hours) and divide by the number of doses per day (6, as doses are every 4 hours). This gives us (25 kg * 300 mg/kg / 24 hours) / 6 doses = 1875 mg. Therefore, the nurse should administer 1875 mg for each dose.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) BP 70/40, which should be reported immediately to a healthcare provider. A significant decrease in heart rate in a child with a congenital heart defect could indicate worsening cardiac function, which may lead to inadequate cardiac output and subsequent hypotension, reflected in the blood pressure reading. This finding is critical as it signals a potential cardiac decompensation and the need for immediate medical intervention. Option A) Oxygen saturation 94% is within the normal range for a pediatric patient and does not indicate an acute issue requiring immediate attention. Option B) RR of 25 breaths/minute is also within the normal range for a 3-year-old child and is not a concerning finding in isolation. Option C) Urine output 20 mL/hr is slightly on the lower side but may not be an immediate cause for concern in the absence of other critical symptoms or abnormal vital signs. Educationally, this question highlights the importance of recognizing subtle changes in vital signs in pediatric patients, especially those with underlying cardiac conditions. It emphasizes the need for prompt assessment and intervention when there is a significant deviation from baseline parameters, particularly in high-risk populations like children with congenital heart defects. Regular monitoring and early detection of deteriorating conditions can help prevent adverse outcomes in pediatric patients with complex health needs.