The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?
Suggest placing the iron drops in the orange juice and then feeding the infant.
Give the mother positive feedback about the way she administered the medication.
Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
Tell the mother to follow the iron drops with infant formula instead of orange juice.
The Correct Answer is B
The nurse should give the mother positive feedback about the way she administered the medication. Giving the infant orange juice after administering the iron drops is a good practice because vitamin C in the orange juice can enhance the absorption of iron. The other options (A, C, and D) are not appropriate actions for the nurse to take in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: (B) Counsel the client about the risks and benefits of using oral contraceptives.
Rationale:
(A) Encourage the client to discuss her need for contraceptives with her parents: Encouraging open communication with parents is important, but this action might not be the most appropriate in this context. The client has expressed a desire for confidentiality, and respecting her autonomy is essential, particularly when it comes to sensitive topics like sexual health.
(B) Counsel the client about the risks and benefits of using oral contraceptives: Providing counseling about the risks and benefits of oral contraceptives is the most appropriate action. It ensures the client is informed and able to make a decision that is right for her health and circumstances. The nurse can also discuss other contraceptive options and provide education on safe sex practices. This approach respects the client's autonomy and privacy while ensuring she receives the necessary information to make an informed choice.
(C) Explain that she needs parental approval to receive contraceptives: In many areas, adolescents have the right to obtain contraceptives without parental consent. Requiring parental approval might not only be legally incorrect but could also discourage the client from seeking necessary healthcare, potentially putting her at risk.
(D) Tell the client how to receive a variety of free oral contraceptives from the clinic: While providing information about accessing contraceptives is helpful, this option alone does not address the need for thorough counseling about the risks and benefits. It's important to ensure that the client understands the implications of using oral contraceptives and has the opportunity to ask questions and receive guidance tailored to her individual needs.
Correct Answer is D
Explanation
Hypoparathyroidism is a disorder in which the parathyroid glands produce insufficient amounts of parathyroid hormone, which regulates calcium and phosphorus levels in the body. In hypoparathyroidism, there is a decreased level of calcium in the blood, which can result in carpal spasm or tetany when pressure is applied to the upper arm.
Therefore, the nurse should review the child's calcium level (D) to determine if it is within the normal range. Low calcium levels can cause muscle spasms, seizures, and cardiac arrhythmias. Hypocalcemia may also result in other symptoms such as numbness, tingling, and muscle cramps.
Potassium (A), chloride (B), and sodium (C) are electrolytes that play important roles in various physiological processes in the body, but they are not directly related to the development of carpal spasm in a child with hypoparathyroidism. While hypokalemia (low potassium) or hyponatremia (low sodium) can cause muscle weakness or cramps, these conditions are not typically associated with carpal spasm in hypoparathyroidism.
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