Nokea
A newborn with a repaired gastroschisis is transferred to the pediatric unit after several days in the pediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Speak to the healthcare provider about instituting physical therapy.
- B. Offer a pacifier for non-nutritive sucking.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Use sterile technique during feedings.
Correct Answer: B
Rationale: Offering a pacifier for non-nutritive sucking promotes oral feeding skills and emotional stability, supporting normal growth and development in infants with gastroschisis repair.
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A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?
- A. Compare the child's vital signs over the past three weeks.
- B. Counsel the parents to pay more attention to the child.
- C. Ask the boy to describe a typical day at school.
- D. Conduct a complete neurological assessment.
Correct Answer: C
Rationale: Asking the boy to describe a typical day at school helps identify potential stressors or psychosocial factors contributing to his non-specific symptoms.
During a sports physical examination, a 15-year-old female expresses her desire for oral contraceptives. She mentions that she is sexually active and prefers not to inform her parents. What should be the nurse's course of action?
- A. Advise the client about the risks and benefits associated with oral contraceptives.
- B. Inform the client about how to obtain a variety of free oral contraceptives from the clinic.
- C. Encourage the client to discuss her contraceptive needs with her parents.
- D. Explain that parental consent is required to receive contraceptives.
Correct Answer: A
Rationale: Educating about risks and benefits respects autonomy and informs decision-making.
During a routine clinic visit, a nurse finds that a 5-year-old girl's systolic blood pressure is above the 90th percentile. What should be the nurse's subsequent action?
- A. Refer the child to the healthcare provider and schedule a blood pressure evaluation in two weeks.
- B. Perform a comprehensive assessment and avoid repeated blood pressure measurements during the examination.
- C. Take the child's blood pressure three times during the visit and record the highest reading.
- D. Measure the blood pressure twice more during the visit and calculate the average of the three readings.
Correct Answer: D
Rationale: Averaging three readings ensures accuracy of elevated blood pressure findings.
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.
A mother brings her 2-month-old to the well-baby clinic. She mentions that when she kisses her baby, the infant's skin tastes salty. What standard diagnostic test should the nurse prepare the mother for to screen for cystic fibrosis (CF)?
- A. Fecal-fat test.
- B. Sweat-chloride test.
- C. Pulmonary-function test.
- D. Potassium chloride test.
Correct Answer: B
Rationale: The sweat-chloride test is the standard diagnostic for cystic fibrosis, detecting elevated chloride levels.