The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:

Correct Answer: D

Rationale: The correct response is D: "She is just starting to salivate and hasn't learned to swallow the saliva." At 3 months old, infants often start drooling due to increased salivation as their salivary glands develop. This response acknowledges normal infant development and provides an explanation for the observed behavior. Choice A (You're right, drooling is usually a sign of the first tooth) is incorrect because while drooling can be associated with teething, it is not the primary reason for drooling in a 3-month-old. Choice B (It would be unusual for a 3-month-old to be getting her first tooth) is incorrect because teething can start as early as 3 months, although it is more common around 6 months. Choice C (This could be the sign of a problem with the salivary glands) is incorrect as it jumps to a less likely conclusion of a salivary gland issue without considering the normal developmental process of salivation in infants

Correct Answer: A

Rationale: The correct answer is A, between the scapulae. Tactile fremitus is most intense over areas where there is a solid lung structure close to the chest wall, such as between the scapulae where the main bronchi are located. This proximity allows for better transmission of vibrations generated by vocalization. Choices B, C, and D are incorrect because they do not align with the anatomical locations of solid lung structures. The third intercostal space, midaxillary line, and lower lobes do not provide the necessary proximity to produce intense tactile fremitus.

Correct Answer: C

Rationale: The correct answer is C because in the 26th week of pregnancy, it is normal for women to experience an increased awareness of their breathing without actual shortness of breath. This is due to the growing fetus putting pressure on the diaphragm, leading to a sensation of needing to breathe more frequently. The nurse's response should reassure the woman that her experience is normal and not a cause for concern. Choice A is incorrect because the diaphragm does not become fixed during pregnancy, rather it is pushed upward by the growing uterus. Choice B is incorrect because although estrogen levels increase during pregnancy, causing changes in the rib cage, this does not directly lead to difficulty in breathing. Choice D is incorrect because the increased awareness of breathing is not solely due to the increased oxygen demand from the fetus but also from the physical changes in the body due to pregnancy.

Correct Answer: C

Rationale: The correct answer is C: "Where did the rash first appear—on the nipple, the areola, or the surrounding skin?" This question is crucial because the location of the rash can provide valuable clues about the potential cause. For example, a rash on the nipple may point towards issues like Paget's disease, while a rash on the areola could suggest eczema or contact dermatitis. On the other hand, a rash on the surrounding skin may indicate a fungal infection or allergic reaction. By identifying the precise location of the rash, the nurse can narrow down the differential diagnosis and develop an appropriate care plan. Summary: A: "Is the rash raised and red?" - This question focuses on the appearance of the rash but does not provide specific information about its location, which is more critical in determining the cause. B: "Does it appear to be cyclic?" - This question is not as directly relevant to identifying the cause of the rash compared to pinpointing its location. D

Correct Answer: C

Rationale: The correct sequence of the electrical stimulus in the cardiac cycle is SA node → AV node → bundle of His → bundle branches. The rationale is as follows: 1. The SA node initiates the electrical impulse in the heart. 2. The impulse travels to the AV node, which serves as a delay mechanism to ensure proper coordination of atrial and ventricular contractions. 3. From the AV node, the impulse then travels to the bundle of His, which conducts the impulse to the bundle branches. 4. Finally, the impulse is transmitted through the bundle branches to the Purkinje fibers, which then distribute the impulse throughout the ventricles for coordinated contraction. Therefore, choice C is correct as it accurately represents the sequential pathway of the electrical stimulus in the cardiac cycle. Choices A, B, and D are incorrect as they do not follow the physiologically accurate sequence of the cardiac conduction system.