Which of the following abilities would a nurse expect a 4-month-old infant to perform?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Grasping a rattle when it is offered. At 4 months old, infants typically start developing their fine motor skills, including the ability to grasp objects that are presented to them. This milestone is part of their normal developmental progression and signifies their growing coordination and muscle control. Option A) Sitting up without support is typically achieved around 6-8 months of age, so it would be too advanced for a 4-month-old infant. Option B) Responding to pleasure with smiles is a social and emotional milestone that infants usually exhibit from birth onwards, so it is not specific to a 4-month-old. Option D) Turning from either side to the back is also a motor skill that is usually mastered later, around 5-6 months of age. Understanding these developmental milestones is crucial for nurses caring for pediatric patients as it helps them assess a child's growth and development accurately. By recognizing what abilities are expected at different ages, nurses can identify any potential delays or abnormalities early on, leading to timely interventions and support for the child and their family.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Ask them about the pain. In the context of assessing pain in toddlers, this technique would be least effective. Toddlers, especially younger ones, may not have the ability to effectively communicate their pain through verbal means. They may have limited vocabulary and struggle to express their feelings accurately. This can lead to unreliable or incomplete information being provided when directly asking about pain. Option B) Observe them for restlessness is a more effective technique as toddlers often display restlessness or agitation when they are in pain. This can be a visible cue for the nurse to assess and investigate further. Option C) Watch their face for grimaces is also a valuable technique as facial expressions can provide important clues about pain in toddlers. Grimacing, frowning, or other expressions of discomfort can indicate pain even when verbal communication is limited. Option D) Listen for pain cues in their cries is another effective technique, as toddlers may express pain through changes in the tone, intensity, or frequency of their cries. Crying patterns can offer valuable insights into their level of discomfort. Educational Context: In pediatric nursing, assessing pain in toddlers can be challenging due to their limited communication skills. Nurses must rely on a combination of observational cues, non-verbal communication, and knowledge of age-appropriate pain behaviors to accurately assess and manage pain in this population. Understanding these techniques is crucial for providing optimal care and ensuring the well-being of pediatric patients.

Correct Answer: B

Rationale: The correct answer is B) Mastery of language ambiguities. When a child engages in telling jokes and riddles excessively, it is often a sign of their developing language skills and cognitive abilities. This behavior demonstrates their understanding of wordplay, humor, and linguistic nuances. It is a positive sign of cognitive development and creativity, rather than a negative behavior. Option A) Inadequate parental attention is incorrect because the behavior described does not necessarily indicate a lack of parental attention. Option C) Inappropriate peer influence is incorrect as the behavior is more likely linked to individual cognitive development rather than peer influence. Option D) Excessive television watching is incorrect as it does not directly relate to the child's behavior of telling jokes and riddles. Educationally, understanding these nuances in child behavior helps nurses and healthcare professionals appreciate the different ways children express themselves and develop. It also highlights the importance of looking at behaviors within the context of child development rather than jumping to conclusions about negative influences or inadequate caregiving. This knowledge can guide nurses in providing appropriate support and guidance to both children and their families.

Correct Answer: D

Rationale: In this scenario, the best option to help the 2-year-old who is crying inconsolably after the mother leaves would be option D) Favorite blanket. This choice is the most appropriate as it provides comfort and security to the child during the mother's absence. The favorite blanket is a familiar object that can offer a sense of familiarity and safety, helping to soothe the child's distress. For young children, attachment to comfort objects like a favorite blanket is a common and effective coping mechanism in stressful situations. It provides emotional support and can help reduce anxiety and promote a sense of security. In contrast, options A, B, and C are not as effective in providing immediate comfort to the child in this situation. Taking a nap may not be feasible or helpful when the child is upset and needs comfort. A peer play group may not address the child's immediate emotional needs for comfort and security, and introducing a large cuddly dog may not be appropriate or comforting for all children, especially in a hospital setting where the child may already be feeling overwhelmed. In an educational context, understanding the significance of comfort objects like a favorite blanket in providing emotional support to young children is crucial for healthcare providers, especially in pediatric settings. It is essential to consider the child's emotional well-being and individual coping mechanisms when managing distress in young patients. By recognizing the importance of familiar objects in pediatric care, healthcare providers can better support children during challenging and stressful situations.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Distended bladder. When the fundus is palpated on the right side of the abdomen above the expected level, it indicates that the bladder is full and pushing the uterus upwards and to the right. This finding is crucial to recognize in postpartum care as a distended bladder can lead to uterine displacement, increased risk of postpartum hemorrhage, and discomfort for the mother. Option B) Normal involution is incorrect because the fundus being palpated above the expected level is not indicative of the expected physiological process of the uterus returning to its pre-pregnancy size. Option C) Been lying on her right side too long is incorrect as it does not explain the physiological reason behind the fundus being palpated higher on the right side of the abdomen. Option D) Stretched ligaments that are unable to support the uterus is incorrect because this choice does not address the immediate concern of a distended bladder, which requires prompt intervention to prevent complications. For nursing students and healthcare professionals, understanding the assessment findings related to postpartum care, including fundal height and position, is essential for providing safe and effective care to postpartum mothers. Prompt recognition of a distended bladder can prevent complications and promote the well-being of both the mother and the newborn.