Nokea
A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia. After returning to the postoperative neonatal unit, her RR and HR have increased during the last hour. Which intervention should the nurse implement?
- A. Notify the healthcare provider of these findings
- B. Administer a PRN analgesic as prescribed
- C. Document the findings in the infant's medical record
- D. Comfort the infant by swaddling and gently rocking
Correct Answer: A
Rationale: In a postoperative neonatal setting, an increase in respiratory rate (RR) and heart rate (HR) in an infant could indicate pain or distress. It is crucial for the nurse to notify the healthcare provider promptly to assess the infant's condition and provide appropriate interventions. Prompt communication with the healthcare provider ensures timely evaluation and management of the infant's discomfort or distress, promoting optimal postoperative recovery and comfort.
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The nurse provides information about the human papillomavirus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?
- A. Use of protective barriers during sexual activity prevents most strains of HPV infection
- B. Most adolescents are not honest about being sexually active
- C. Not all strains of HPV will be covered if given at a later date
- D. Immunity must be established to prevent future HPV infection and the risk for cervical cancer
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What should the nurse do first for a 6-year-old with asthma showing a prolonged expiratory phase, wheezing, and 35% of personal best peak expiratory flow rate (PEFR)?
- A. Administer a prescribed bronchodilator.
- B. Encourage the child to cough and take deep breaths.
- C. Report the findings to the healthcare provider.
- D. Identify the triggers that precipitated this attack.
Correct Answer: A
Rationale: Administering a bronchodilator is the priority action in managing an acute asthma exacerbation in a child. Bronchodilators help to relax the muscles around the airways, opening them up and improving breathing. This intervention aims to address the immediate breathing difficulty and should be done promptly to provide relief for the child.
The nurse is caring for a 4-year-old child who is hospitalized with pneumonia. The child is receiving IV antibiotics and oxygen therapy. The nurse notes that the child's respiratory rate is 40 breaths per minute, and the oxygen saturation is 92%. What is the nurse's priority action?
- A. Increase the child's oxygen flow rate
- B. Notify the healthcare provider
- C. Encourage the child to take deep breaths
- D. Auscultate the child's lung sounds
Correct Answer: D
Rationale: In this scenario, the child is hospitalized with pneumonia, receiving IV antibiotics and oxygen therapy. With a high respiratory rate and decreased oxygen saturation, auscultating the child's lung sounds is the priority action. This assessment can provide crucial information about the child's respiratory status, such as the presence of adventitious sounds or decreased air entry, which can guide further interventions and help in evaluating the effectiveness of the current treatments.
A mother brings her school-aged daughter to the pediatric clinic for evaluation of her anti-epileptic medication regimen. What information should the nurse provide to the mother?
- A. The medication dose will be tapered over a period of 2 weeks when being discontinued
- B. If seizures return, multiple medications will be prescribed for another 2 years
- C. A dose of valproic acid (Depakote) should be available in the event of status epilepticus
- D. Phenytoin (Dilantin) and phenobarbital (Luminal) should be taken for life
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The caregiver is caring for a 3-year-old child with a diagnosis of gastroenteritis. The child has had several episodes of vomiting and diarrhea over the past 24 hours. What is the caregiver's priority assessment?
- A. Monitor the child's weight
- B. Assess the child's hydration status
- C. Evaluate the child's nutritional intake
- D. Check the child's temperature
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.