Nokea
A healthy postpartum mother who is breastfeeding her term infant tells the nurse that she has noticed that her roommate is feeding iron-enriched formula to her newborn. The mother asks if she should be giving her baby supplemental iron. Which response by the nurse is correct?
- A. “Your breast milk provides all the iron your baby needs.”
- B. “You,not your baby will need an iron supplement daily.”
- C. “Your pediatrician will prescribe iron drops for your baby.”
- D. “You should feed your baby iron-fortified formula once daily.”
Correct Answer: A
Rationale: Breast milk provides sufficient highly bioavailable iron for term infants making supplementation unnecessary. Maternal iron supplements or formula feeding are not required.
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How should the nurse position a child who is about to undergo a lumbar puncture?
- A. Prone position
- B. Fowler's position
- C. Supine position
- D. Side-lying position
Correct Answer: D
Rationale: The side-lying position with the back curved and knees flexed maximizes spinal flexion, facilitating access to the subarachnoid space for a lumbar puncture.
For the teenager recovering from an appendectomy, which nursing measure is most appropriate to prevent respiratory complications during the postoperative period?
- A. Administer a bronchodilator by inhalation.
- B. Administer oxygen by nasal cannula.
- C. Give the child a corticosteroid.
- D. Have the child use an incentive spirometer.
Correct Answer: D
Rationale: Using an incentive spirometer encourages deep breathing, preventing atelectasis and pneumonia, common respiratory complications post-surgery due to immobility and anesthesia.
After assisting in the delivery of a full-term infant with anencephaly,the parents ask the nurse to explain treatments that might be available for their infant. Which statement should be the basis for the nurse’s response?
- A. Immediate surgery is necessary to repair the congenital defect.
- B. Anencephaly is incompatible with life; only palliative care should be provided.
- C. A shunting procedure will be necessary initially to relieve intracranial pressure.
- D. Antibiotics are needed initially before any treatment is started.
Correct Answer: B
Rationale: Anencephaly lacking cerebral hemispheres and skull is incompatible with life warranting only palliative care. Surgery shunting or antibiotics cannot correct it.
Which nursing action is most appropriate when caring for a child experiencing a sickle cell crisis?
- A. Apply heat to the affected joints.
- B. Administer oxygen as ordered.
- C. Encourage vigorous physical activity.
- D. Provide a high-sodium diet.
Correct Answer: B
Rationale: Administering oxygen as ordered improves oxygenation, critical during a sickle cell crisis to counteract hypoxia caused by vaso-occlusion and reduced oxygen-carrying capacity.
Which diversional activity is best for meeting the burned child's developmental needs?
- A. Reading the newspaper
- B. Coloring simple designs
- C. Playing with an action figure
- D. Playing a solitary card game
Correct Answer: B
Rationale: Coloring simple designs is a developmentally appropriate activity for a school-age child, promoting fine motor skills and creativity while being feasible for a bedridden patient with burns.