Nokea
When caring for a 2-year-old girl who is wheezing and has difficulty breathing, which interview question would provide the most useful information related to the symptoms of the child?
- A. Inquiring about child safety in the home
- B. Asking about the temperament of the child
- C. Asking about the child's diet
- D. Asking the parents if they smoke in the home
Correct Answer: D
Rationale: Asking the parents if they smoke in the home is the most relevant question as exposure to secondhand smoke can exacerbate respiratory symptoms like wheezing and difficulty breathing in children. This information is crucial for identifying potential triggers for the child's symptoms. Inquiring about child safety in the home, asking about the child's temperament, and inquiring about the child's diet, while important aspects of care, may not directly address the respiratory symptoms the child is experiencing.
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A child is admitted with extensive burns. The nurse notes burns on the child's lips and singed nasal hairs. The nurse should suspect that the child has a(n)
- A. chemical burn
- B. inhalation injury
- C. electrical burn
- D. hot-water scald
Correct Answer: B
Rationale: Burns on the lips and singed nasal hairs indicate inhalation injury, suggesting the child has inhaled hot gases or smoke. This presentation is common in cases where the respiratory tract is exposed to hot gases or smoke, leading to potential airway compromise. Choice A, chemical burn, is incorrect because there is no mention of exposure to chemicals, and the symptoms described are more indicative of inhalation injury. Choice C, electrical burn, is incorrect as there is no evidence of electrical involvement in the scenario provided. Choice D, hot-water scald, is incorrect because the presence of singed nasal hairs points more towards inhalation injury than a scald from hot water, emphasizing the need to prioritize airway management and respiratory support.
What intervention best meets a major developmental need of a newborn in the immediate postoperative period?
- A. Giving a pacifier to the newborn
- B. Putting a mobile over the newborn's crib
- C. Providing the newborn with a soft, cuddly toy
- D. Warming the newborn's formula before feeding
Correct Answer: A
Rationale: The correct answer is giving a pacifier to the newborn. Sucking is a natural reflex and a source of comfort for newborns, especially postoperatively. A pacifier can help meet their developmental needs by providing soothing comfort. Choices B, C, and D do not directly address the major developmental need related to the newborn's comfort and reflexes postoperatively. Putting a mobile over the crib, providing a cuddly toy, or warming formula, although potentially beneficial in other contexts, do not specifically target the developmental need of sucking for comfort. Offering a pacifier is a safe and effective way to address this developmental need in newborns.
A child is being assessed for suspected intussusception. What clinical manifestation is the nurse likely to observe?
- A. Projectile vomiting
- B. Currant jelly stools
- C. Abdominal distension
- D. Constipation
Correct Answer: C
Rationale: The correct clinical manifestation that a nurse is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception is a medical emergency where a part of the intestine folds into itself, causing obstruction. Abdominal distension is a common symptom due to the obstruction and the build-up of gases and fluids. While currant jelly stools (Choice B) are a classic sign of intussusception, they are typically seen in later stages of the condition and may not be present during the initial assessment. Projectile vomiting (Choice A) is more commonly associated with conditions like pyloric stenosis. Constipation (Choice D) is not a typical manifestation of intussusception; the condition usually presents with severe colicky abdominal pain and possible passage of blood and mucus in stools.
Your assessment of a mother in active labor reveals that a limb is protruding from the vagina. Management of this condition should include:
- A. Positioning the mother in a semi-Fowler's position, administering oxygen, and providing transport
- B. Positioning the mother in a head-down position with her hips elevated, administering oxygen, and providing transport
- C. Applying gentle traction to the protruding limb to remove pressure of the fetus from the umbilical cord
- D. Giving the mother 100% oxygen and attempting to manipulate the protruding limb so that delivery can occur
Correct Answer: B
Rationale: In a situation where a limb is protruding from the vagina during active labor, the correct management includes positioning the mother in a head-down position with her hips elevated. This position helps relieve pressure on the umbilical cord and improves oxygenation to the fetus. Administering oxygen is important to ensure adequate oxygen supply to both the mother and the baby. Providing transport is necessary for prompt transfer to a medical facility for further management. Applying gentle traction to the protruding limb is not recommended as it can cause harm to the baby and should be avoided. Giving 100% oxygen and attempting to manipulate the protruding limb is not the correct approach and can potentially lead to further complications.
Parents of a sick infant talk with a nurse about their baby. One parent says, "I am so upset; I didn't realize our baby was ill." What major indication of illness in an infant should the nurse explain to the parent?
- A. Grunting respirations
- B. Excessive perspiration
- C. Longer periods of sleep
- D. Crying immediately after feedings
Correct Answer: C
Rationale: The correct answer is C. Longer periods of sleep than usual can be a sign of illness in infants. When an infant sleeps more than usual, it can indicate that the baby is conserving energy due to an underlying condition. Grunting respirations (choice A) can be a sign of respiratory distress, not just an indication of illness. Excessive perspiration (choice B) can occur due to various reasons and is not a specific major indication of illness. Crying immediately after feedings (choice D) is a common behavior in infants and not necessarily a major indication of illness.