Nokea
A nurse is caring for a child with measles.
- A. "Provide diversional activities such as video games."'
- B. "Maintain isolation for 48 hr after the rash resolves."'
- C. "Keep the child warm with adequate undergarments and bedding."'
- D. "Administer vitamin A supplements as prescribed."'
Correct Answer: D
Rationale: The correct answer is D because administering vitamin A supplements is a standard treatment for measles to reduce complications and improve recovery. Vitamin A deficiency is common in children with measles, and supplementation can help boost the immune system and reduce the severity of the illness. Providing diversional activities (choice A) may be suitable but does not directly address the medical needs of the child. Maintaining isolation (choice B) is important but typically lasts until 4 days after rash onset, not just 48 hours after rash resolution. Keeping the child warm (choice C) is a general comfort measure and may not directly impact measles treatment.
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The nursery nurse delays the first bottle feeding of a newborn. Which is the most common reason for the nurse's actions? The infant has:
- A. a blood glucose of 45 gm/dL
- B. a respiratory rate above 60
- C. blue hands and feet
- D. a heart murmur
Correct Answer: B
Rationale: The correct answer is B: a respiratory rate above 60. The nurse delays feeding because a high respiratory rate may indicate respiratory distress, making feeding unsafe. Feeding can lead to aspiration in infants with respiratory issues. A blood glucose of 45 gm/dL (choice A) is low but not typically a reason to delay feeding. Blue hands and feet (choice C) may indicate poor circulation, but it's not a common reason to delay feeding. A heart murmur (choice D) doesn't directly impact feeding safety.
A nurse is checking children at an orthopedic outpatient setting. Which of the following should the nurse expect to see as manifestations of scoliosis?
- A. Pain and an exaggerated lumbar curvature'
- B. Uneven shoulder heights and poorly fitting slacks'
- C. Tenderness and swelling of the spine'
- D. Limited range of motion of the back and a limp'
Correct Answer: B
Rationale: The correct answer is B. Uneven shoulder heights and poorly fitting slacks are common manifestations of scoliosis because the condition causes an abnormal curvature of the spine, leading to uneven shoulders and hips. Pain and exaggerated lumbar curvature (choice A) are not specific manifestations of scoliosis. Tenderness and swelling of the spine (choice C) could indicate other conditions like infection or inflammation, not necessarily scoliosis. Limited range of motion of the back and a limp (choice D) are more indicative of musculoskeletal injuries or disorders, not scoliosis.
A nurse has reinforced teaching to the parent of a 9-month-old infant who has redness in the diaper area and inner thighs. Which of the following statements by the parent indicates a correct understanding of this teaching?
- A. I can use a hair dryer on the reddened skin to help with the drying.
- B. I can use powder after diaper changes to absorb excess moisture.
- C. I can use cloth diapers with rubber outer pants until the rash clears.
- D. I can keep the diaper off to expose the skin to air.
Correct Answer: D
Rationale: Exposing the skin to air helps prevent irritation and promotes healing.
The nurse midwife is concerned about a pregnant client who is suspected of having a TORCH infection. Which is the main reason TORCH infections are grouped together? They are:
- A. benign to the woman but cause death to the fetus.
- B. sexually transmitted.
- C. capable of infecting the fetus.
- D. transmitted to the pregnant woman by a vector.
Correct Answer: C
Rationale: The correct answer is C because TORCH infections (Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes) are grouped together due to their ability to infect the fetus during pregnancy. These infections can lead to severe complications in the developing fetus, including congenital disabilities and even fetal death. Choices A, B, and D do not accurately describe the main reason TORCH infections are grouped together. Choice A focuses on the outcomes for the woman and fetus, not the reason for grouping the infections. Choice B is incorrect as TORCH infections are not primarily sexually transmitted. Choice D is also incorrect as TORCH infections are not transmitted by vectors but through various routes such as transplacentally or through contact with infected bodily fluids.
Which of the following are probable signs, strongly indicating pregnancy?
- A. The presence of fetal heart sounds is a positive sign of pregnancy; quickening is a presumptive sign of pregnancy.
- B. These are presumptive signs. They may indicate pregnancy or they may be caused by other conditions, such as disease processes.
- C. Hegar’s sign is a softening of the lower uterine segment, and Chadwick's sign is the bluish or purplish color of the cervix as a result of the increased blood supply and increased estrogen. Ballottement occurs when the cervix is tapped by an examiner's finger and the fetus floats upward in the amniotic fluid and then falls downward.
- D. These are presumptive signs that might indicate pregnancy, but they might be caused by other conditions, such as disease processes.
Correct Answer: C
Rationale: The correct answer is C because Hegar's sign and Chadwick's sign are considered probable signs of pregnancy. Hegar's sign indicates softening of the lower uterine segment, a physiological change that typically occurs in pregnancy. Chadwick's sign refers to the bluish or purplish color of the cervix due to increased blood supply and estrogen levels in pregnancy. These signs are more specific to pregnancy compared to presumptive signs like quickening, which can be caused by other conditions. Ballottement is a technique used to assess fetal movement and position, not a sign indicating pregnancy certainty. Therefore, choices A, B, and D are incorrect as they refer to presumptive signs or signs that could be caused by conditions other than pregnancy.