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A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Nontender, protruding abdomen
- C. Natural loss of deciduous teeth
- D. Palpable fontanels
Correct Answer: B
Rationale: The correct answer is B: Nontender, protruding abdomen. In toddlers, it is normal to have a nontender, protruding abdomen due to the physiological characteristics of their developing digestive system and musculature. This is because toddlers have less developed abdominal muscles and a larger liver in proportion to their body size, causing their abdomen to appear slightly distended. This finding is considered normal and does not typically indicate any underlying health issues. The other options are incorrect because: A: Head circumference exceeding chest circumference is not a typical finding in a 2-year-old toddler. C: Natural loss of deciduous teeth typically occurs around age 6-7, not in toddlers. D: Fontanels should be closed by 18 months, so palpable fontanels in a 2-year-old would be abnormal.
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A home health nurse is teaching a new parent about caring for his 1-week-old infant. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will avoid picking up my baby too often to keep from spoiling him.
- B. I will hang a pastel-colored mobile 24 inches above my baby's crib.
- C. I can use a firm pillow to prop up the bottle when feeding my baby.
- D. I will place a ticking clock nearby to soothe my baby throughout the day.
Correct Answer: B
Rationale: The correct answer is B: "I will hang a pastel-colored mobile 24 inches above my baby's crib." This statement indicates an understanding of the teaching because hanging a mobile can provide visual stimulation for the infant, promoting cognitive development. It also helps in soothing and calming the baby.
Incorrect choices:
A: Incorrect because picking up the baby frequently is not spoiling and is important for bonding and meeting the baby's needs.
C: Incorrect because using a firm pillow to prop up the bottle can be a choking hazard and is not recommended for feeding infants.
D: Incorrect because placing a ticking clock nearby can actually be a suffocation risk and is not recommended for soothing babies.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the epiglottis becomes inflamed and can lead to airway obstruction. Intubation may be necessary to secure the airway and ensure the child can breathe. It is a priority action to maintain the child's oxygenation and ventilation. Obtaining a throat culture (B) can be important for diagnosis but is not the immediate priority. Suctioning the child's oropharynx (C) can trigger a spasm and worsen the obstruction. Cool mist tent (D) is not indicated in the management of epiglottitis.
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
- A. Perform the procedure prior to meals.
- B. Hold hand flat to perform percussions on the child.
- C. Administer a bronchodilator after the procedure.
- D. Perform the procedure twice each day.
Correct Answer: A
Rationale: The correct answer is A. Performing postural drainage prior to meals helps prevent aspiration of food or stomach contents during the procedure. Postural drainage is typically done 1-2 hours after meals to minimize the risk of aspiration. Holding the hand flat (B) is incorrect as cupped hands are used for percussion to avoid injury. Administering a bronchodilator after (C) can lead to increased mucous production. Performing the procedure twice daily (D) is generally recommended, but the timing in relation to meals is crucial.
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room
- B. Administer aspirin to the child for fever
- C. Use droplet precautions when caring for the child
- D. Assess the child for health spots
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella (chickenpox) is highly contagious and spreads through airborne particles. Placing the child in a negative air pressure room helps prevent the spread of the virus to other patients and staff. Administering aspirin to a child with varicella can lead to Reye's syndrome, making choice B incorrect. Droplet precautions are used for illnesses like influenza or pertussis, not varicella, so choice C is incorrect. Choice D is incorrect because the characteristic rash in varicella is not described as health spots.
A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
- A. Take pancrelipase.
- B. Complete oral hygiene.
- C. Eat a meal.
- D. Use an albuterol inhaler.
Correct Answer: D
Rationale: The correct answer is D: Use an albuterol inhaler. Prior to postural drainage, the client with cystic fibrosis should use an albuterol inhaler to help open up the airways and facilitate effective mucus clearance during the procedure. Albuterol is a bronchodilator that helps to relax the muscles in the airways, making it easier to breathe and improving the effectiveness of postural drainage. Pancrelipase (choice A) is taken with meals to aid in digestion, so it is not necessary before postural drainage. Completing oral hygiene (choice B) is important but not directly related to postural drainage. Eating a meal (choice C) may lead to discomfort during the procedure. The priority is to ensure clear airways with the use of the albuterol inhaler.