A nurse is assisting in the care of a toddler who has been taking oral ferrous sulfate drops for iron deficiency anemia. Which of the following data collection findings indicates that the medication is effective?

Decreased hemoglobin

Weight loss

Tarry, green stools

Pica

Answer and Explanation

The Correct Answer is C

Iron deficiency anemia in toddlers is commonly treated with oral iron supplementation such as Ferrous sulfate to restore hemoglobin levels and replenish iron stores. The effectiveness of therapy is evaluated by improvements in oxygen-carrying capacity and resolution of deficiency symptoms. Iron therapy also produces characteristic changes in stool color and consistency due to unabsorbed iron. Monitoring both laboratory values and expected side effects helps determine therapeutic response.

Rationale:
A. Decreased hemoglobin indicates worsening anemia rather than improvement. Effective iron therapy should lead to an increase in hemoglobin levels over time as iron is utilized for red blood cell production. A decline suggests inadequate absorption, poor compliance, or ongoing blood loss rather than therapeutic success.

B. Weight loss is not an indicator of effective iron therapy and may suggest poor nutritional status or another underlying condition. Successful treatment of iron deficiency anemia is associated with improved energy levels and normal growth patterns in toddlers. Continued weight loss would require further evaluation rather than being considered a positive response.

C. Tarry, green stools are a common and expected side effect of iron supplementation such as ferrous sulfate. This occurs due to unabsorbed iron passing through the gastrointestinal tract and oxidizing in stool. This is not harmful, but it is often used as an indirect indicator that the medication is being taken and processed by the body.

D. Pica, the ingestion of non-food substances such as dirt or ice, is a symptom of iron deficiency anemia rather than an indicator of improvement. Effective iron therapy should reduce or eliminate pica behaviors as iron stores normalize. Persistence of pica suggests that treatment has not yet corrected the underlying deficiency.

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Correct Answer is A

Explanation

The postpartum period involves close monitoring for complications following delivery, even when the birth is uncomplicated. One of the most serious risks during this time is thromboembolic events due to hypercoagulability, venous stasis, and vascular injury associated with pregnancy and delivery. Early recognition of warning signs is critical to prevent life-threatening conditions such as deep vein thrombosis (DVT) and pulmonary embolism. Nurses must distinguish normal postpartum findings from abnormal findings requiring urgent intervention.

Rationale:
A. A calf that is edematous and tender is an abnormal finding and may indicate deep vein thrombosis. Postpartum clients are at increased risk of thrombus formation due to physiological hypercoagulability. Unilateral swelling, pain, and tenderness in the calf should be reported immediately to prevent progression to pulmonary embolism, which is a medical emergency.

B. Nipple tenderness with breastfeeding is a common and expected finding in the early postpartum period. It is usually related to improper latch or initial nipple sensitivity as breastfeeding is established. This can be managed with education and support and does not require urgent reporting.

C. Hemorrhoids in the rectal area are a frequent postpartum occurrence due to increased venous pressure during pregnancy and delivery. Although they may cause discomfort, they are not typically dangerous and can be managed with conservative measures such as stool softeners and topical treatments.

D. Moderate lochia rubra 24 hours postpartum is an expected finding. Lochia rubra consists of red, bloody vaginal discharge that occurs in the early postpartum period as the uterus sheds its lining. As long as the amount is within expected limits and not excessive or foul-smelling, it is considered normal.

A. Limit directions for the client to three at a time. B. Discourage the client from reminiscing C. Provide finger foods for the client at mealtimes. D. Encourage the client to eat meals in their room.

Correct Answer is C

Explanation

Dementia is a progressive neurocognitive disorder that affects memory, judgment, language, and the ability to perform activities of daily living. Clients often experience confusion, decreased attention span, and impaired executive functioning, which can interfere with safe and adequate nutrition. Nursing care focuses on promoting independence, ensuring safety, and simplifying tasks to reduce frustration. Interventions should support functional abilities while maintaining dignity and adequate nutritional intake.

Rationale:
A. Limiting directions to three at a time is not appropriate because clients with dementia typically benefit from one simple instruction at a time. Providing multiple directions, even up to three, can overwhelm cognitive processing and increase confusion. Instructions should be short, clear, and given step-by-step to enhance understanding and compliance.

B. Discouraging the client from reminiscing is incorrect because reminiscence can be therapeutic for clients with dementia. Talking about past experiences can improve mood, reduce anxiety, and support orientation to self. It is often used as a supportive communication strategy to enhance emotional well-being and cognitive engagement.

C. Providing finger foods at mealtimes is appropriate because it supports independence in eating for clients with dementia who may have difficulty using utensils. Finger foods reduce the complexity of the task and help maintain adequate nutritional intake despite cognitive or motor impairments. This intervention promotes autonomy and reduces the risk of malnutrition.

D. Encouraging the client to eat meals in their room is not recommended because social interaction during meals can improve food intake and reduce agitation. Eating in a communal setting, when safe, provides cues for appropriate eating behavior and enhances stimulation. Isolation may worsen confusion and decrease nutritional intake in clients with dementia.

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A nurse is assisting in the care of a toddler who has been taking oral ferrous sulfate drops for iron deficiency anemia. Which of the following data collection findings indicates that the medication is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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