A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include?
- A. The child will continue to sleep and be pain-free
- B. Parents cannot administer additional medication with the button
- C. The pump can deliver baseline and bolus dosages
- D. There is a high risk of overdose, so monitoring is done every 15 minutes
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid cleaning the skin
- B. Bathe the infant with sterile water
- C. Cleanse the skin with a gentle alkaline-based soap and water
- D. Thoroughly rinse the skin with plain water after bathing
Correct Answer: B
Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.
The parents of a child with sickle cell anemia ask why their child did not have a sickle cell crisis until he was approximately 6 months old. How should the nurse respond?
- A. Your child probably had a crisis, and you were unaware of the symptoms.
- B. Are you sure your child has sickle cell anemia and not sickle cell trait?
- C. Affected children can be asymptomatic in early infancy because of high levels of fetal hemoglobin that inhibit sickling.
- D. Have you asked your doctor about this yet?
Correct Answer: C
Rationale: The correct answer is C. Fetal hemoglobin (HbF) is present in high levels during early infancy, inhibiting sickling unlike adult hemoglobin (HbS). As the levels of HbF decrease and HbS increases, the risk of sickling and crises becomes more pronounced, typically after 6 months of age. Choice A is incorrect because it assumes the crisis went unnoticed, which is not supported by medical knowledge. Choice B is incorrect as it questions the child's diagnosis rather than explaining the phenomenon of delayed crises. Choice D is incorrect as it does not provide the parents with the necessary information regarding their query.
Which action should the nurse implement when taking an axillary temperature?
- A. Take the temperature through one layer of clothing
- B. Add a degree to the result when recording
- C. Place the tip of the thermometer under the arm in the center of the axilla
- D. Hold the child's arm away from the body while taking the temperature
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The parents of an 8-month-old infant voice concern to the nurse that their infant is not developing motor skills as the infant should. What question would be appropriate for the nurse to ask in determining if their fears are warranted?
- A. Does the infant move a toy back and forth from one hand to the other?
- B. Is the infant able to drink from a cup by oneself?
- C. Is the infant able to hold a pencil and scribble on paper?
- D. Does the infant place toys into a box or container and take them out?
Correct Answer: A
Rationale: The correct answer is A. By 8 months, an infant should be able to transfer objects between hands, which is an important motor skill milestone. This action shows coordination and developing fine motor skills. Choices B, C, and D involve more advanced motor skills that are typically not expected at 8 months of age. Drinking from a cup, holding a pencil to scribble, and engaging in purposeful play with toys are skills that develop later in infancy.
At a well-visit, a mother voices concern that her 30-month-old has a smaller vocabulary than other children in his daycare. The nurse should:
- A. Admit the child to the hospital
- B. Assess the child for other age-appropriate development
- C. Suggest that the child is hearing impaired
- D. Explain that the child has a significant developmental delay
Correct Answer: B
Rationale: When a parent expresses concern about a child's development, it is essential to conduct a comprehensive assessment of all areas of development before jumping to conclusions. Choosing option B allows the nurse to evaluate the child for other age-appropriate developmental milestones to determine if there are any delays or concerns. Admitting the child to the hospital (option A) is not necessary at this point and may cause unnecessary stress. Suggesting hearing impairment (option C) without proper evaluation can lead to misdiagnosis. Explaining a significant developmental delay (option D) should only be done after a thorough assessment and diagnosis.