Nokea
A child is admitted with suspected pyloric stenosis. Which of the following should be included in the plan of care?
- A. Monitor for signs of metabolic acidosis
- B. Observe for projectile vomiting
- C. Provide large, infrequent feedings to allow for rest
- D. Place the infant in a supine position after feeding
Correct Answer: B
Rationale: The correct answer is B: 'Observe for projectile vomiting.' Projectile vomiting is a classic sign of pyloric stenosis, caused by obstruction at the pylorus. Choice A is incorrect as metabolic alkalosis, not acidosis, often occurs due to the loss of hydrochloric acid from persistent vomiting. Choice C is incorrect as frequent, small feedings are preferred to prevent overloading the stomach. Choice D is incorrect as placing the infant in an upright position after feeding can help reduce reflux.
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What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?
- A. The dorsal gluteal muscle
- B. The vastus lateralis muscle
- C. The ventral gluteal muscle
- D. The biceps muscle
Correct Answer: B
Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.
With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight?
- A. 10th percentile
- B. 75th percentile
- C. 85th percentile
- D. 95th percentile
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?
- A. Ask the parent when the neck was injured
- B. Refer for immediate medical evaluation
- C. Continue assessment to determine the cause of the neck pain
- D. Record head lag on the assessment record and continue the assessment of the child
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the appropriate method for measuring the temperature of a 2-day-old neonate?
- A. Tympanic
- B. Oral
- C. Axillary
- D. Rectal
Correct Answer: C
Rationale: For a 2-day-old neonate, the most suitable method to measure temperature is the axillary method. This approach is considered safe and appropriate for neonates, minimizing the risk of injury. Tympanic temperature measurement may not be as accurate in neonates due to their small ear canals. Oral temperature measurement is not recommended for neonates as they may not be able to hold a thermometer properly in their mouths. Rectal temperature measurement is invasive and carries a higher risk of injury and should be avoided unless absolutely necessary.
During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which?
- A. A normal finding
- B. A sign of a possible visual defect and a need for vision screening
- C. An abnormal finding requiring referral to an ophthalmologist
- D. A sign of small hemorrhages, which usually resolve spontaneously
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.