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A nurse is assessing the fontanels of an infant. Which of the following findings should the nurse recognize as an expected finding?
- A. The posterior fontanel is open.
- B. The anterior fontanel is open.
- C. Both fontanels are the same size.
- D. Both fontanels show molars.
Correct Answer: B
Rationale: The correct answer is B: The anterior fontanel is open. The anterior fontanel is typically open in infants to allow for brain growth and development. It is a normal finding during infancy and should close by around 18 months of age. Choice A is incorrect because the posterior fontanel closes shortly after birth. Choice C is incorrect because the fontanels are not expected to be the same size; the anterior fontanel is larger than the posterior fontanel. Choice D is incorrect because the presence of molars in the fontanels would not be expected and could indicate a medical issue.
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A nurse is assessing a 7-year-old child who has diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Increased capillary refill
- B. Thirst
- C. Shakiness
- D. Decreased appetite
Correct Answer: C
Rationale: The correct answer is C: Shakiness. Hypoglycemia in a child with diabetes can lead to a decrease in blood sugar levels, causing symptoms like shakiness due to the body's response to low glucose levels. Increased capillary refill (A) is not typically associated with hypoglycemia. Thirst (B) is more commonly seen in hyperglycemia. Decreased appetite (D) can be a symptom of hypoglycemia, but shakiness is a more specific indicator.
A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Increased intracranial pressure
- C. Upper extremity hypotension
- D. Frequent nosebleeds
Correct Answer: A
Rationale: Correct Answer: A - Weak femoral pulses
Rationale: Coarctation of the aorta results in narrowing of the aorta, leading to decreased blood flow to the lower extremities. This causes weak or absent femoral pulses due to reduced blood supply. The other choices are incorrect as coarctation of the aorta typically does not directly cause increased intracranial pressure, upper extremity hypotension, or frequent nosebleeds. These symptoms are more commonly associated with other conditions such as head trauma, vascular issues, or nasal conditions.
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Apply a warm compress to the operative site once daily.
- B. Administer analgesics on a scheduled basis for the first 24 hr.
- C. Give cromolyn nebulized solution every 8 hr.
- D. Offer small amounts of clear liquids 6 hr following surgery.
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. This is essential postoperatively to manage pain effectively and improve the child's comfort level. Pain management is crucial in the early stages following surgery to prevent complications and aid in the child's recovery. Applying a warm compress (choice A) may not be appropriate for the surgical site and could potentially cause harm. Giving cromolyn nebulized solution (choice C) is not indicated for pain management postoperatively. Offering clear liquids (choice D) too soon after surgery could increase the risk of complications such as nausea, vomiting, or aspiration.
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 that can cause rapid airway obstruction. Intubation ensures a secure airway and oxygenation. Throat culture (B) is not a priority in this acute situation. Suctioning (C) can provoke spasm and worsen obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
A nurse is assessing a school-age child who is receiving morphine. For which of the following adverse effects should the nurse monitor?
- A. Hypertension
- B. Bradypnea
- C. Stevens-Johnson syndrome
- D. Prolonged wound healing
Correct Answer: B
Rationale: The correct answer is B: Bradypnea. Morphine is an opioid that can cause respiratory depression, leading to bradypnea (slow breathing). The nurse should monitor the child's respiratory rate regularly as a safety precaution. Hypertension (A), Stevens-Johnson syndrome (C), and prolonged wound healing (D) are not typically associated with morphine use in school-age children. Monitoring for these adverse effects would not be a priority in this situation.