Nokea
18 years old P1 presents in outpatient department ten days after delivery with tender hot painful swelling in right breast. She also complains of fever with rigors. What will be the most likely management:
- A. Antibiotics.
- B. Analgesics.
- C. Incision & drainage.
- D. Conservative management.
- E. Lactation inhibition.
Correct Answer: C
Rationale: The symptoms suggest a breast abscess which requires incision and drainage for effective treatment especially with systemic symptoms like fever. Antibiotics alone are insufficient for an abscess and other options are inappropriate.
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Which of the following assessment findings would alert the nurse that the child may be exhibiting early signs of sepsis?
- A. Increased level of pain
- B. Disorientation
- C. Decreased urine output
- D. Jitteriness
Correct Answer: B
Rationale: Disorientation can indicate early sepsis in burn patients, reflecting systemic infection affecting the central nervous system. Other signs like fever or tachycardia may also occur, but disorientation is a critical early warning.
The physician orders 500 mg of a medication to be given I.V. over 4 hours. The medication is diluted in 100 mL of fluid. What is the hourly flow rate in milliliters?
Correct Answer: 25 mL/hour
Rationale: Calculation: 100 mL over 4 hours = 100 ÷ 4 = 25 mL/hour. Since no options are provided, the calculated rate is noted for accuracy.
While caring for the small-for-gestational-age newborn (SGA),the nurse notes slight tremors of the extremities a high-pitched cry and an exaggerated Moro reflex. In response to these assessment findings what should be the nurse’s first action?
- A. Assess the infant’s blood sugar level.
- B. Document the findings in the infant’s medical record.
- C. Immediately inform the pediatrician of the symptoms.
- D. Assess the infant’s axillary temperature.
Correct Answer: A
Rationale: SGA infants risk hypoglycemia due to low glycogen stores causing tremors high-pitched cry and exaggerated reflexes. Checking blood sugar is the priority action.
The nurse reviews the labor and delivery record of the 2-hour-old male newborn and sees this notation: “40 weeks’ gestation,large for gestational (LGA) age.” In response to this information it is most important for the nurse to plan to assess the infant carefully for which condition?
- A. Acrocyanosis
- B. Undescended testicles
- C. Intact clavicles
- D. Hypothermia
Correct Answer: C
Rationale: LGA infants risk birth trauma like fractured clavicles due to macrosomia. Acrocyanosis is normal testicles are typically descended at term and LGA infants are less prone to hypothermia.
Which statement by the parents indicates they understand the home care needs for a child with sickle cell anemia?
- A. We'll limit our child's fluid intake to prevent swelling.
- B. We'll encourage our child to rest during sickle cell crises.
- C. We'll give our child aspirin for fever.
- D. We'll avoid taking our child to the doctor for regular checkups.
Correct Answer: B
Rationale: Encouraging rest during sickle cell crises reduces oxygen demand and prevents exacerbation of vaso-occlusive episodes, indicating understanding of home care needs.