Nokea
A newborn, who has had gastroschisis repair, is transferred to the pediatric unit after spending several days in the pediatric intensive care unit. The infant is on parenteral nutrition and continuous enteral feedings. What action should the nurse include in the plan of care to promote the infant's normal growth and development?
- A. Discuss with the healthcare provider about starting physical therapy
- B. Offer a pacifier for non-nutritive sucking
- C. Confirm placement of the enteral tube with an abdominal x-ray
- D. Use sterile technique during feedings .
Correct Answer: B
Rationale: Non-nutritive sucking via a pacifier stimulates the sucking reflex and supports feeding development, promoting normal growth.
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The nurse is caring for a child with hypoparathyroidism who exhibits a carpal spasm when pressure is applied to the upper arm. Which laboratory value should the nurse review?
- A. Sodium
- B. Calcium
- C. Potassium
- D. Chloride
Correct Answer: B
Rationale: Carpal spasm (Trousseau's sign) indicates hypocalcemia, common in hypoparathyroidism.
An adolescent client reports to the nurse of walking with a limp due to pain localized in the right knee which worsens at night but denies any recent injury or trauma. The nurse observes swelling and tenderness in the right lower thigh and imaging results reveal radial ossification in the soft tissues. What condition should the nurse consider as the probable cause of the findings?
- A. Osteosarcoma
- B. Hemosiderosis
- C. Growing pains
- D. Rhabdomyolysis
Correct Answer: A
Rationale: Symptoms and radial ossification suggest osteosarcoma, a common bone tumor in adolescents.
The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. What action should the nurse take first?
- A. Obtain point-of-care glucose.
- B. Assess urine for ketones.
- C. Check blood pressure.
- D. Review prior insulin prescriptions.
Correct Answer: A
Rationale: Symptoms suggest hyperglycemia; point-of-care glucose testing confirms this and guides treatment.
The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
- A. Place a toy in the child's hands while listening to the breath sounds.
- B. Allow the child to use a stethoscope on a stuffed animal.
- C. Offer the child bubbles before the stethoscope is placed.
- D. Have the child blow a cotton ball and have the parent catch it.
Correct Answer: B
Rationale: Using a stethoscope on a stuffed animal engages the child, reducing fear and improving cooperation.
The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?
- A. Divide the gluteal area into quarters and give IM into the upper outer quadrant.
- B. Administer the injection into the middle of the lateral aspect of the thigh.
- C. Use a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage.
- D. Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process.
Correct Answer: B
Rationale: The vastus lateralis in the thigh is the preferred IM site for toddlers, ensuring safe delivery.