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What should be included in the nursing plan of care for a 6-month-old infant admitted to the pediatric unit with a diagnosis of respiratory syncytial virus (RSV)?
- A. Place the infant in a warm, dry environment.
- B. Allow parents and siblings to visit.
- C. Maintain standard and contact precautions.
- D. Administer prescribed antibiotics immediately.
Correct Answer: C
Rationale: The correct answer is C: Maintain standard and contact precautions. RSV is highly contagious, primarily spread through respiratory secretions. Therefore, it is crucial to implement infection control measures such as standard and contact precautions to prevent the spread of the virus to other patients, staff, and visitors. Choice A is incorrect because warmth and dryness are not specific interventions for RSV; the focus should be on infection control. Choice B may increase the risk of exposing others to RSV, so limiting visitors is recommended. Choice D is unnecessary because RSV is a viral infection, and antibiotics are not effective against viruses.
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Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. Management should include
- A. oxygen, uterine massage, and transport
- B. oxygen, placement on the left side, and transport
- C. oxygen, treatment for shock, and uterus massage during transport
- D. oxygen, internal vaginal pads, and treatment of shock during transport
Correct Answer: C
Rationale: Postpartum hemorrhage can lead to shock due to excessive bleeding. Oxygen should be provided to support oxygenation. Treatment for shock, which includes maintaining vital signs and perfusion, is crucial. Uterine massage helps prevent further bleeding by promoting uterine contraction. This combination of interventions is essential for managing postpartum hemorrhage effectively. Choices A, B, and D lack the comprehensive approach needed for managing postpartum hemorrhage, as they do not address the treatment of shock, which is vital in this scenario.
A parent asks the nurse what to do when their toddler has temper tantrums. What play materials should the nurse suggest to offer the child as another way of expressing anger?
- A. Ball and bat
- B. Wad of clay
- C. Punching bag
- D. Pegs and pounding board
Correct Answer: D
Rationale: Pegs and pounding boards are the most suitable choice for toddlers to express their emotions constructively. These materials provide a safe and acceptable way for toddlers to release anger and frustration through physical activity. Options A, B, and C may not be as effective or safe for toddlers dealing with temper tantrums. A ball and bat may encourage aggressive behavior rather than constructive expression. A wad of clay might not be ideal for channeling anger, and a punching bag can potentially promote violent behavior, which is not appropriate for toddlers.
The nurse is caring for an infant with candidal diaper rash. Which topical agent would the nurse expect the healthcare provider to order?
- A. Corticosteroids.
- B. Antifungals.
- C. Antibiotics.
- D. Retinoids.
Correct Answer: B
Rationale: The correct answer is B: Antifungals. Candidal diaper rash is caused by a yeast infection and is best treated with antifungal agents. Corticosteroids (choice A) may worsen fungal infections by suppressing the immune response. Antibiotics (choice C) are used to treat bacterial infections, not fungal infections like candidal diaper rash. Retinoids (choice D) are not typically used to treat candidal diaper rash in infants; they are more commonly used for dermatological conditions like acne.
What is the first action to take before administering tube feeding to an infant?
- A. Irrigate the tube with water.
- B. Offer a pacifier to the infant.
- C. Slowly instill 10 mL of formula.
- D. Place the infant in the Trendelenburg position.
Correct Answer: B
Rationale: The correct first action before administering tube feeding to an infant is to offer a pacifier. Providing a pacifier stimulates the sucking reflex, aiding in digestion and providing comfort to the infant. Irrigating the tube with water (Choice A) is not typically the initial step and could potentially introduce unnecessary fluid into the infant's system. Slowly instilling formula (Choice C) should only be done after ensuring the tube is appropriately placed. Placing the infant in the Trendelenburg position (Choice D) is not necessary for tube feeding and could pose risks such as aspiration.
A nurse is teaching the parents of a child with a diagnosis of epilepsy about seizure precautions. What should the nurse include in the teaching?
- A. Keep a diary of seizure activity
- B. Administer antiepileptic medication only when a seizure occurs
- C. Restrict the child's activities to prevent seizures
- D. Teach seizure first aid to family members
Correct Answer: D
Rationale: Teaching seizure first aid to family members is crucial for ensuring the child's safety during a seizure. Keeping a diary of seizure activity (choice A) is important for tracking patterns and triggers but does not directly relate to immediate safety during a seizure. Administering antiepileptic medication only when a seizure occurs (choice B) is incorrect as medications should be given as prescribed to maintain therapeutic levels. Restricting the child's activities to prevent seizures (choice C) is not an appropriate approach as it may limit the child's quality of life without guaranteeing seizure prevention.