a child has surgery for pyloric stenosis, you offer him his first feeding post operatively, following this it would be best to position him:
- A. supine, to prevent sudden infant death syndrome
- B. Trendelenburg, to prevent pressure on the suture line
- C. on his right side to encourage flow through the pylorus
- D. prone, to encourage maximum digestion of milk curds
Correct Answer: C
Rationale: Positioning the child on his right side after surgery for pyloric stenosis helps to promote the flow of formula through the pylorus and into the intestines. Placing the child in this position can aid in preventing any potential complications from the surgery and promote proper digestion. The right side position assists in the drainage of the stomach contents, thereby reducing the risk of complications related to the surgery and promoting the healing process. It is essential to follow this positioning recommendation as part of the post-operative care for a child who has undergone surgery for pyloric stenosis.
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A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as:
- A. Milia
- B. Lanugo
- C. Whiteheads
- D. Mongolian spots
Correct Answer: A
Rationale: Milia are small, whitish, pinpoint spots that commonly occur in newborns due to retained sebaceous secretions in the skin. They are commonly seen on the nose and can also appear on the cheeks and chin. Milia are not indicative of any illness and tend to disappear on their own without any treatment. They are a benign and temporary skin condition in newborns.
Which of the ff. nursing interventions will help prevent complications in the patient with Bell's Palsy?
- A. Megavitamin therapy
- B. Application of ice to the affected area
- C. Elastic bandages
- D. Lubricating eye drops
Correct Answer: D
Rationale: Bell's Palsy is a condition that affects the facial nerve, leading to weakness or paralysis of the facial muscles. One common complication of Bell's Palsy is the inability to fully close the affected eye, which can result in corneal exposure and dryness. Lubricating eye drops help prevent dryness and protect the cornea from damage due to inadequate eye closure. Using lubricating eye drops regularly can help maintain the eye's moisture and prevent potential complications such as corneal abrasions and infections, which are common in patients with Bell's Palsy. Megavitamin therapy, application of ice, and elastic bandages are not typically indicated for preventing complications in patients with Bell's Palsy.
Why should the nurse closely monitor older adults when they are receiving IV therapy? Choose all that apply
- A. Because their defense mechanisms are less efficient
- B. Because they are prone to fluid overload
- C. Because they are prone to reduced renal efficiency
- D. Because they have inadequate intake of dietary fiber
Correct Answer: E
Rationale: Older adults should be closely monitored when receiving IV therapy because their defense mechanisms are less efficient (A) as they age, making them more susceptible to infections and complications from invasive procedures like IV therapy. Additionally, older adults are prone to reduced renal efficiency (C), which can affect their ability to excrete excess fluids and electrolytes properly. Monitoring for signs of fluid overload and renal impairment is crucial in this population to prevent adverse outcomes related to IV therapy.
The age by which the child can pull to stand, starting to pincer grasp, and plays pat-a-cake is
- A. 6 mo
- B. 7 mo
- C. 8 mo
- D. 9 mo
Correct Answer: D
Rationale: These milestones are typically achieved around 9 months of age.
During the initial assessment, he is placed in a modified Trendelenburg position. What desired effect should the position have on the client?
- A. An increase in the client's blood pressure
- B. An increase in the client's respiratory rate f. An increase in the client's heart rate h. A decrease in blood loss
- C. An increase in the client's respiratory rate
- D. An increase in the client's heart rate h. A decrease in blood loss
Correct Answer: A
Rationale: Placing a client in a modified Trendelenburg position involves having the client lie flat on the back with the legs elevated above the level of the heart. The main purpose of this position is to help increase blood pressure in cases of hypotension or shock. By raising the legs above the heart level, gravity helps to facilitate the return of venous blood to the heart, which can increase cardiac output and, consequently, blood pressure. This position is commonly used in clinical settings to help improve perfusion to vital organs and assist in stabilizing a client's blood pressure.