Nokea
A healthcare professional is reviewing the clinical records of infants and children with cardiac disorders who developed heart failure. What did the healthcare professional determine is the last sign of heart failure?
- A. Tachypnea
- B. Tachycardia
- C. Peripheral edema
- D. Periorbital edema
Correct Answer: C
Rationale: Peripheral edema is often the last sign of heart failure in infants and children as it indicates significant fluid retention and circulatory compromise. Tachypnea (Choice A) and tachycardia (Choice B) are early signs of heart failure due to the body's compensatory mechanisms. Periorbital edema (Choice D) can occur in heart failure but is not typically the last sign; it is more commonly associated with renal or hepatic dysfunction.
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A 2-week-old infant is admitted with a tentative diagnosis of a ventricular septal defect. The parents report that their baby has had difficulty feeding since coming home after birth. What should the nurse consider before responding?
- A. Feeding problems are common in neonates.
- B. Inadequate sucking is not significant in the absence of cyanosis.
- C. Ineffective sucking and swallowing may be early indications of a heart defect.
- D. Many neonates retain mucus, which may interfere with feeding for several weeks.
Correct Answer: C
Rationale: In this scenario, the nurse should consider that ineffective sucking and swallowing in a 2-week-old infant could be early signs of a heart defect such as a ventricular septal defect. This is crucial information as it can guide further assessment and management. Choice A is incorrect because while feeding problems can be common in neonates, in this case, the specific context of a suspected heart defect should be prioritized. Choice B is incorrect as inadequate sucking can indeed be significant, especially when considering potential underlying heart issues, regardless of the presence of cyanosis. Choice D is incorrect as while mucus retention can affect feeding, in this case, the focus should be on the possibility of a heart defect rather than a temporary issue like mucus interference.
A nurse is planning an evening snack for a child receiving Novolin N insulin. What is the reason for this nursing action?
- A. To encourage the child to stay on the diet.
- B. Energy is needed for immediate utilization.
- C. Extra calories will help the child gain weight.
- D. Nourishment helps to counteract late insulin activity.
Correct Answer: D
Rationale: The correct answer is D. Novolin N insulin peaks in the evening, leading to a higher risk of hypoglycemia during this time. Providing a snack before bedtime helps counteract the late insulin activity and prevent hypoglycemia. Choice A is incorrect as the primary reason for the snack is related to insulin activity rather than diet compliance. Choice B is not directly related to the timing of Novolin N insulin administration. Choice C is unrelated to the specific need for a snack in the evening to address insulin activity.
What should the nurse suggest to a parent asking for advice on managing their child's earache and fever?
- A. Applying a warm compress to the affected ear
- B. Giving the child a cold drink
- C. Administering acetaminophen
- D. Taking the child to the emergency department
Correct Answer: A
Rationale: The correct answer is to suggest applying a warm compress to the affected ear. This can help alleviate pain and discomfort associated with the earache. Giving a cold drink (Choice B) may not address the underlying issue and is not a recommended treatment for earaches. Administering acetaminophen (Choice C) can help reduce fever but may not directly target the earache. Taking the child to the emergency department (Choice D) is usually not necessary for a common earache unless there are severe symptoms or complications present.
A 12-month-old infant has become immunosuppressed during a course of chemotherapy. When preparing the parents for the infant's discharge, what information should the nurse give concerning the measles, mumps, and rubella (MMR) immunization?
- A. It should not be given until the infant reaches 2 years of age.
- B. Infants who are receiving chemotherapy should not be given these vaccines.
- C. It should be given to protect the infant from contracting any of these diseases.
- D. The parents should discuss this with their healthcare provider at the next visit.
Correct Answer: B
Rationale: Live vaccines, like the measles, mumps, and rubella (MMR) vaccine, should not be administered to immunosuppressed infants, such as those undergoing chemotherapy. The weakened immune system of these infants may not be able to handle live vaccines safely, potentially leading to severe complications. Therefore, it is crucial to avoid giving live vaccines like MMR to infants receiving chemotherapy. Choice A is incorrect as delaying the MMR vaccine until the infant reaches 2 years of age is not the main concern in this scenario. Choice C is incorrect because although MMR vaccination is important for disease prevention, it should not be given to immunosuppressed infants. Choice D is incorrect as immediate action is needed to prevent potential harm from live vaccines in immunosuppressed infants.
A parent asks the nurse what to do for their child who has an earache and fever. What should the nurse suggest?
- A. Applying a warm compress to the affected ear
- B. Giving the child a cold drink
- C. Administering acetaminophen
- D. Taking the child to the emergency department
Correct Answer: A
Rationale: Applying a warm compress to the affected ear is a recommended home remedy for earaches as it can help reduce pain and discomfort. The warmth can also help improve circulation and promote drainage if there is fluid buildup. Giving a cold drink (Choice B) is not typically beneficial for earaches and fever. Administering acetaminophen (Choice C) can help reduce fever and alleviate pain, but addressing the earache directly with a warm compress is a more targeted approach. Taking the child to the emergency department (Choice D) is not necessary for a common earache unless there are severe symptoms or complications present.