Nokea
Which of the following techniques represents the most appropriate method of opening the airway of an infant with no suspected neck injury?
- A. lift up the chin and hyperextend the neck
- B. tilt the head back without hyperextending the neck
- C. gently lift the chin while maintaining slight flexion of the neck
- D. perform the technique as you would for an older child or adult
Correct Answer: B
Rationale: The correct technique for opening the airway of an infant with no suspected neck injury is to tilt the head back without hyperextending the neck. This method helps to keep the airway open without risking injury to the infant's delicate neck structures. Choice A, lifting up the chin and hyperextending the neck, can potentially harm the infant's neck. Choice C, gently lifting the chin while maintaining slight flexion of the neck, is not as effective as tilting the head back. Choice D is incorrect as infants require a different approach compared to older children or adults due to their anatomical differences.
You may also like to solve these questions
When teaching an adolescent with type 1 diabetes about dietary management, what should the nurse include?
- A. Meals should be eaten at home.
- B. Foods should be weighed using a gram scale.
- C. A ready source of glucose should be available.
- D. Specific foods should be cooked for the adolescent.
Correct Answer: C
Rationale: The correct answer is C: A ready source of glucose should be available. When managing type 1 diabetes, it is crucial to have a quick source of glucose readily available in case of hypoglycemia. This ensures that the adolescent can quickly raise their blood sugar levels to prevent complications. Choices A, B, and D are incorrect as they do not address the immediate need for glucose in managing hypoglycemia. While it is important for meals to be consumed regularly and in a controlled manner, specifying that they should be eaten at home or foods weighed using a gram scale is not as critical as ensuring a quick source of glucose in emergency situations.
Which is the most appropriate nursing diagnosis for a child with acute glomerulonephritis?
- A. Risk for injury related to malignant process and treatment
- B. Fluid volume deficit related to excessive losses
- C. Fluid volume excess related to decreased plasma filtration
- D. Fluid volume excess related to fluid accumulation in tissues and third spaces
Correct Answer: C
Rationale: The most appropriate nursing diagnosis for a child with acute glomerulonephritis is 'Fluid volume excess related to decreased plasma filtration.' Acute glomerulonephritis is characterized by inflammation in the glomeruli, leading to decreased plasma filtration and retention of fluid. This results in fluid volume excess rather than deficit, making choice C the correct answer. Choice A is incorrect because acute glomerulonephritis is not primarily associated with a malignant process. Choice B is incorrect as the condition typically presents with fluid volume excess rather than deficit. Choice D is also incorrect as fluid accumulation in tissues and third spaces is not a typical manifestation of acute glomerulonephritis.
Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis?
- A. Risk for injury related to malignant process and treatment
- B. Fluid volume deficit related to excessive losses
- C. Fluid volume excess related to decreased plasma filtration
- D. Fluid volume excess related to fluid accumulation in tissues and third spaces
Correct Answer: C
Rationale: The most appropriate nursing diagnosis for a child with acute glomerulonephritis is fluid volume excess related to decreased plasma filtration. Acute glomerulonephritis is characterized by inflammation of the glomeruli in the kidneys, leading to decreased plasma filtration and retention of fluid. This results in fluid volume excess rather than fluid deficit (choice B) or fluid accumulation in tissues and third spaces (choice D). The diagnosis of 'risk for injury related to malignant process and treatment' (choice A) is not directly related to the pathophysiology of acute glomerulonephritis.
A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?
- A. Quality of the cry
- B. Signs of dehydration
- C. Coughing up feedings
- D. Characteristics of the stool
Correct Answer: B
Rationale: The correct answer is B: Signs of dehydration. Infants with hypertrophic pyloric stenosis (HPS) are at high risk of dehydration due to frequent vomiting. Assessing for signs of dehydration, such as decreased urine output, dry mucous membranes, and sunken fontanelles, is crucial for early intervention and management. Choices A, C, and D are not the most critical assessments for HPS. The quality of the cry (choice A) may not provide as much relevant information in this case. Coughing up of feedings (choice C) may be a symptom but is not as crucial as assessing for dehydration. Characteristics of the stool (choice D) are important but assessing for signs of dehydration takes precedence due to the immediate risk it poses to the infant's health.
While performing a visual inspection of a 30-year-old woman in active labor, you can see the umbilical cord at the vaginal opening. After providing high concentration oxygen, what should you do next?
- A. massage the uterus to facilitate delivery of the fetus
- B. relieve pressure from the cord with your gloved fingers
- C. place the mother on her left side and provide rapid transport
- D. elevate the mother's lower extremities and provide immediate transport
Correct Answer: B
Rationale: In the scenario described, the priority is to relieve pressure from the umbilical cord protruding from the vaginal opening by gently pushing it back inside using your gloved fingers. This action helps prevent cord compression, maintains blood flow to the fetus, and ensures fetal oxygenation. Massaging the uterus (Choice A) is not appropriate in this situation as it can potentially worsen the cord compression. Placing the mother on her left side and providing rapid transport (Choice C) can be considered after relieving the pressure on the cord. Elevating the mother's lower extremities and providing immediate transport (Choice D) is not the correct approach when dealing with a visible umbilical cord; instead, the focus should be on relieving pressure from the cord to prevent fetal compromise.