A 3-month-old child with developmental dysplasia of the hip...

A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction?

A. I should leave the harness on during diaper changes.
B. I will adjust the harness straps every 3-5 days.
C. I will inspect the skin under the straps 2-3 times daily.
D. The harness should keep my baby's legs bent and spread apart.

Correct Answer: B

Rationale: The harness straps should only be adjusted by a healthcare provider to ensure proper fit and treatment efficacy. Other statements reflect correct understanding of harness care.

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The nurse reinforces teaching for the parents of a child with impetigo. Which of the following statements by a parent indicates correct understanding of teaching? Select all that apply.

A. I should wash my hands before and after touching the infected area.
B. I will clean the infected area with alcohol before applying the antibiotic ointment.
C. I will separate my child's clothing from other laundry and wash them with hot water.
D. My child's fingernails should be kept short and well-filed.
E. The infection could easily spread to other children who come in contact with my child.

Correct Answer: A,C,D,E

Rationale: Hand hygiene, separating laundry, keeping nails short, and recognizing the contagious nature of impetigo are correct. Cleaning with alcohol is inappropriate as it may irritate the skin.

An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, 'Where do babies come from?' What is the nurse's best response to the parent?

A. When a child asks a question, give a simple answer.
B. Children ask many questions, but are not looking for answers.
C. This question indicates interest in sexual development.
D. Full and detailed answers should be given to all questions.

Correct Answer: A

Rationale: When a child asks a question, give a simple answer. Honesty is important, but answers should be simple and age-appropriate, providing only the information the child is ready to understand.

The nurse is reinforcing teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply.

A. Drinking more caffeinated drinks such as tea and soda helps to stimulate the bowel.
B. Having a routine for bowel movements is important, but I should not wait if I feel the urge.
C. I can use an over-the-counter laxative every other day if needed.
D. I should try to eat more fruits and vegetables every day.
E. Increasing my daily exercise level may help keep my bowel movements regular.

Correct Answer: B,D,E

Rationale: A routine, high-fiber diet, and exercise prevent constipation. Caffeine can dehydrate, and frequent laxative use is not recommended.

The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.

A. Prepare to suction the client.
B. Turn the client to a side-lying position.
C. Restrain the client's upper extremities.
D. Request assistance from other staff members.
E. Use a tongue blade to depress the client's tongue.

Correct Answer: A,B,D

Rationale: Suctioning, side-lying position, and assistance protect the client. Restraining or using a tongue blade can cause injury.

The nurse is talking with the parent of a 1-day-old female client who has a small amount of blood-tinged, mucoid vaginal drainage. Which of the following statements would be most appropriate for the nurse to make?

A. Laboratory tests will need to be performed to determine your baby's hormone levels.
B. The health care provider will prescribe a medication to stop the bleeding.
C. We will continue to monitor the amount, color, and consistency of the drainage.
D. What visitors have been present since your baby was born?

Correct Answer: C

Rationale: Blood-tinged vaginal drainage in a newborn is often due to maternal hormone exposure and typically resolves. Monitoring is appropriate.