Nokea
A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood cultures.
- B. Administer penicillin.
- C. Prepare for a cesarean section.
- D. Cover the lesion with a dressing.
Correct Answer: C
Rationale: Cesarean section prevents neonatal herpes transmission during delivery with active lesions.
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The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?
- A. Avoid any smoking inside the house.
- B. Give infant the full course of antibiotics.
- C. Schedule visit for pneumococcal vaccine.
- D. Instill benzocaine otic drops regularly.
Correct Answer: D
Rationale: Benzocaine otic drops provide pain relief but do not prevent infections. Regular use may mask symptoms, delaying treatment. Avoiding smoke, completing antibiotics, and vaccinating reduce infection risk.
The mother of a 4-month-old baby girl asks the nurse when should she introduce solid foods to her infant. The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry.
- B. Awakens once for nighttime feedings.
- C. Gives up a bottle for a cup.
- D. Opens mouth when food comes her way.
Correct Answer: D
Rationale: Opening the mouth for food, along with head control and sitting support, indicates readiness for solids around 4-6 months.
A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?
- A. Complete the assessment while allowing the child to cry.
- B. Explain to the child the reasons an examination is needed.
- C. Talk to the mother and gradually focus on the child's toy.
- D. Request extra staff to help with the nursing assessments.
Correct Answer: C
Rationale: Engaging the mother and using the child's toy as a distraction builds trust, reducing anxiety and encouraging cooperation.
The nurse is caring for a child with a unilateral long-leg cast applied for the correction of club foot. Which action is most important for the nurse to perform?
- A. Palpate femoral pulses.
- B. Compare temperature of both legs.
- C. Monitor capillary refill of the toes.
- D. Examine for spontaneous movement.
Correct Answer: C
Rationale: Monitoring capillary refill ensures adequate circulation in the casted limb, detecting complications like compartment syndrome.
Following a vaginal delivery, the nurse places the neonate under the radiant warmer, provides naso-oropharyngeal suction, and dries the neonate's skin to elicit spontaneous respirations. The newborn heart rate is 100 beats/minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?
- A. Give blow-by oxygen via cannula.
- B. Start IV infusion in a scalp vein.
- C. Assist neonatologist with intubation.
- D. Provide positive pressure ventilation.
Correct Answer: D
Rationale: Positive pressure ventilation is critical for an apneic newborn to establish breathing and ensure oxygenation, per neonatal resuscitation guidelines.