Nokea
The nurse is discussing activities to promote language development with the parent of a 2-year-old. Which statement by the parent requires follow-up?
- A. I have dress-up clothes set out for my child to play with.
- B. I read brightly-colored picture books with rhymes with my child
- C. I set out a basket of toy cars when other children come to play
- D. I will enroll my child to play on a soccer team
Correct Answer: D
Rationale: Enrolling a 2-year-old in soccer is premature, as it does not directly promote language development and is not age-appropriate. Reading rhyming books and facilitating peer play with toys support language skills.
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A nurse assigns a task to unlicensed assistive personnel. They state, 'We can’t do that.' Which is the best initial response for the nurse to make?
- A. Ask the unlicensed assistive personnel (UAP) the reason for the response
- B. Do the task, but discuss the UAP’s response with the manager
- C. Ignore the UAP’s initial response and repeat the assigned request
- D. Remind the UAP of the importance of teamwork
Correct Answer: A
Rationale: Asking the reason clarifies whether the refusal is due to scope, training, or other issues, promoting collaboration. Performing the task, ignoring, or lecturing avoids addressing the root cause.
A woman comes into the labor suite stating that her water has broken and she is in labor. Which symptoms point to the possible presence of placenta previa?
- A. Sudden knife-like pain in the lower abdomen accompanied by profuse vaginal bleeding
- B. Dark red vaginal discharge that started after she saw the physician this morning
- C. Bright red painless vaginal bleeding
- D. A tender rigid uterine wall and abdomen with no vaginal bleeding evident
Correct Answer: C
Rationale: Placenta previa typically presents with bright red, painless vaginal bleeding due to the placenta covering the cervix, distinguishing it from abruptio placentae or other conditions.
The nurse is caring for a newborn who has a cleft palate. Which of the following actions should the nurse take to promote oral intake? Select all that apply.
- A. Use specialty bottles or nipples
- B. Burp the newborn often when feeding
- C. Feed the newborn in an upright position
- D. Initiate feeding as soon as possible after birth
- E. Encourage the mother to exclusively breastfeed
Correct Answer: A,B,C
Rationale: Specialty bottles, frequent burping, and upright positioning facilitate feeding and reduce aspiration risk in cleft palate. Early feeding is appropriate but not specific, and exclusive breastfeeding is often challenging.
A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.
A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
- A. Provide the ordered humidified oxygen via mask
- B. Suction the mouth and the nose
- C. Check the mouth and radial pulse
- D. Start the ordered intravenous fluids
Correct Answer: C
Rationale: Check the mouth and radial pulse. Assessing airway, breathing, and circulation is the first step in treating toxic ingestion to stabilize the client.