Nokea
A 6-year-old child is scheduled for an IV urography (IVP) in the morning. Which preparatory interventions should the nurse plan to implement? (Select all that apply.)
- A. Clear liquids in the morning before the procedure
- B. Cathartic in the evening before the procedure
- C. Soapsuds enema the morning of the procedure
- D. Insertion of a Foley catheter before the procedure
Correct Answer: A
Rationale: Clear liquids in the morning before the procedure: It is important for the child to have clear liquids before the procedure to ensure proper hydration and to help with visualization during the urography.
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Tic douloureux is a (n) ___ cranial nerve disorder characterized by paroxysms of pain and burning sensations.
- A. 1st
- B. 7th
- C. 5th
- D. 8th
Correct Answer: C
Rationale: Tic douloureux, also known as trigeminal neuralgia, is a disorder of the 5th cranial nerve. This condition is characterized by intense, sharp, stabbing, and burning pain that follows the distribution of one or more branches of the trigeminal nerve. The pain occurs in short, sudden attacks or paroxysms, typically triggered by touching specific trigger points or by activities such as eating or speaking. It is important to correctly identify and diagnose the involvement of the 5th cranial nerve in such cases to provide appropriate treatment options for the patient.
A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?
- A. Hypotension and Bradycardia
- B. Tachypnea and retractions
- C. Acrocyanosis and grunting
- D. The presence of a barrel chest with grunting
Correct Answer: B
Rationale: Respiratory distress syndrome (RDS), also known as hyaline membrane disease, is a condition commonly seen in preterm newborn infants. The two classic signs of RDS are tachypnea (rapid breathing) and retractions. Tachypnea is defined as a respiratory rate greater than 60 breaths per minute in newborn infants. Retractions refer to visible indrawing of the chest wall with each breath, indicating increased work of breathing. These signs are indicative of the infant's struggle to breathe and can suggest the presence of RDS. While acrocyanosis (bluish discoloration of the extremities) and grunting may also be present in infants with RDS, tachypnea and retractions are more specific indicators of respiratory distress. Hypotension and bradycardia are not common signs of RDS. The presence of a barrel chest with grunting is not specific
The child who walks backward, scribbles, and uses spoon and fork has achieved the developmental age of
- A. 9 mo
- B. 12 mo
- C. 15 mo
- D. 18 mo
Correct Answer: D
Rationale: These milestones are typically achieved around 18 months of age.
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. cruises
Correct Answer: D
Rationale: Cruising typically occurs later, around 9-10 months.
A nurse is assessing for jaundice in a dark-skinned newborn. Where is the best place to assess for jaundice in this newborn?
- A. Buttocks
- B. Tip of nose and sclera
- C. Sclera, conjunctiva, and oral mucosa
- D. Palms of hands and soles of feet
Correct Answer: C
Rationale: The best place to assess for jaundice in a dark-skinned newborn is in the sclera, conjunctiva, and oral mucosa. Jaundice, which is caused by elevated levels of bilirubin in the blood, is more easily seen in these areas compared to the skin. While jaundice is commonly assessed on the skin in light-skinned individuals, it may not be as readily apparent in dark-skinned newborns. Therefore, examining the sclera, conjunctiva, and oral mucosa for a yellowish discoloration provides a more reliable indication of jaundice in dark-skinned infants. This approach ensures that healthcare providers can accurately detect and monitor jaundice in newborns of all skin tones.