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,A nurse in a provider’s office is preparing to administer immunizations to a
toddler during a well-child visit. Which of the following actions should the
nurse plan to take?
Correct Answer: Withhold MMR vaccine
A nurse is teaching the parent of an infant who has a Pavlik harness for
the treatment of developmental dysplasia of the hip. Which statement
by the parent indicates an understanding of the proper use of the
harness?
a. "I will place my infant's diapers under the harness straps."
b. "I will remove the harness for diaper changes."
c. "I will keep the harness on for 12 hours each day."
d. "I will place the harness over the infant's clothing."
✔️ Correct Answer: A
Rationale:
The parent should place the infant's diapers under the harness straps to
keep the harness clean and dry while maintaining proper positioning.
Option B is incorrect because the harness should remain in place during
diaper changes to maintain hip positioning. Option C is incorrect
because the harness is typically worn continuously, not for a limited
time each day. Option D is incorrect because the harness should be
worn against the skin, not over clothing. Proper use of the Pavlik
,harness is essential for successful treatment of developmental dysplasia
of the hip.
A nurse is planning care for a toddler who has a serum lead level of 4
mcg/dL. Which action should the nurse plan to take?
a. Schedule the toddler for a yearly rescreening
b. Initiate chelation therapy immediately
c. Admit the toddler to the hospital for observation
d. Refer the family to social services for investigation
✔️ Correct Answer: A
Rationale:
A serum lead level of 4 mcg/dL is below the CDC's recommended
threshold for intervention (5 mcg/dL). The appropriate action is to
schedule the toddler for yearly rescreening to monitor for any increase.
Option B is incorrect because chelation therapy is not indicated at this
level. Option C is incorrect because admission is not necessary. Option D
is incorrect because social services referral is not warranted at this level.
Regular screening is essential for early detection of lead exposure.
A nurse is reviewing a child's medical record. Which of the following
findings should the nurse report to the provider? (Select four.)
a. Arterial blood gases
b. WBC count
c. Oxygen saturation
d. Respiratory assessment
, e. Heart rate
f. Temperature
✔️ Correct Answer: A, B, C, D
Rationale:
Arterial blood gases (Option A), WBC count (Option B), oxygen
saturation (Option C), and respiratory assessment (Option D) are critical
findings that may indicate respiratory compromise or infection and
should be reported to the provider. Option E (Heart rate) and Option F
(Temperature) are important but are not among the four priority
findings specified. These findings help identify conditions such as
respiratory distress, sepsis, or metabolic abnormalities requiring
immediate intervention.
A nurse is caring for a 15-year-old client who is married and scheduled
for a surgical procedure. The client asks, "Who should sign my surgical
consent?" Which response should the nurse make?
a. "You can sign the consent form because you are married."
b. "Your parent must sign because you are a minor."
c. "Your spouse must sign the consent form."
d. "The court must appoint a guardian for you."
✔️ Correct Answer: A
Rationale:
An emancipated minor who is married can legally sign their own
consent form. Option B is incorrect because marriage grants legal
emancipation in most jurisdictions. Option C is incorrect because the
client can sign their own consent. Option D is incorrect because court-