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An infant who has spina bifida
A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?
- A. Place the infant in prone position.
- B. Cover the infant's lesion with a dry cloth.
- C. Feed the infant through an NG tube.
- D. Diapering over a low defect will keep the infant free from infection
Correct Answer: D
Rationale: The correct answer is D. Diapering over a low defect will keep the infant free from infection. This is because keeping the area covered with a diaper helps prevent contamination and infection. Placing the infant in prone position (choice A) is not recommended as it can put pressure on the lesion. Covering the lesion with a dry cloth (choice B) may not provide adequate protection from contamination. Feeding the infant through an NG tube (choice C) is not directly related to preventing infection at the lesion site. Therefore, the best option is to diaper over the defect to maintain hygiene and prevent infection.
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A 9-year-old child who has acute rheumatic fever
A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?
- A. Has your son had a sore throat recently?
- B. Was your son born with this cardiac defect?
- C. Are you aware that your son will have to be in isolation?
- D. Has your child had any injuries recently?
Correct Answer: A
Rationale: Rationale: A sore throat can be a symptom of acute rheumatic fever, which is important for the nurse to assess. This can help in diagnosing the condition and planning appropriate care. Asking about a recent sore throat is relevant to the child's current health status and can guide further assessment and treatment.
Summary:
B: This question is not relevant to acute rheumatic fever.
C: Isolation is not necessary for acute rheumatic fever, so this question is not appropriate.
D: Recent injuries are not directly related to acute rheumatic fever and are not relevant to the child's current condition.
A child who is postoperative following a tonsillectomy
A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage?
- A. Drooling
- B. Continuous swallowing
- C. Poor fluid intake
- D. Increased pain
Correct Answer: B
Rationale: The correct answer is B: Continuous swallowing. This is a clinical manifestation of hemorrhage post-tonsillectomy as the child may be swallowing blood. Drooling (A) is more indicative of airway obstruction. Poor fluid intake (C) is a sign of dehydration. Increased pain (D) can be expected postoperatively but is not specific to hemorrhage.
A child with pneumonia who weighs 20 lb
Primary care provider orders cefazolin (Kefrol) 30 mg/kg in two divided doses per day for a child with pneumonia. Child weighs 20 lb. If the available oral suspension is 125 mg/5ml how many mls per dose should the child receive?
- A. 5.4 mL
Correct Answer: A
Rationale: To calculate the dose, we first convert the child's weight to kg: 20 lb / 2.2 = 9.09 kg. Next, we calculate the total daily dose: 30 mg/kg * 9.09 kg = 272.7 mg/day. Since the dose is divided into 2, each dose is 272.7 mg / 2 = 136.35 mg. To find the volume needed, we divide the dose by the concentration of the suspension: 136.35 mg / 125 mg/5ml = 1.09 ml. However, the dose is divided into two, so each dose is 1.09 ml * 2 = 2.18 ml. Rounded to 1 decimal, the child should receive 2.2 ml per dose, closest to option A: 5.4 ml. Other choices are incorrect as they do not align with the calculated dose.
A toddler who is scheduled to have a lumbar puncture
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?
- A. Restrain the toddler for 1 hr after the procedure.
- B. Swaddle the toddler in a warm blanket.
- C. Ask another nurse to assist with holding the toddler in a prone position.
- D. Place the toddler in a side-lying knee-chest position
Correct Answer: D
Rationale: The correct answer is D: Place the toddler in a side-lying knee-chest position. This position helps to open up the spaces between the vertebrae, making it easier for the healthcare provider to perform the lumbar puncture. Restraint is not recommended as it can cause distress and increase the risk of complications. Swaddling in a warm blanket may not provide the necessary positioning for the procedure. Asking another nurse to assist with holding the toddler in a prone position may not be as effective in achieving the optimal positioning needed for a lumbar puncture.
A child who has spina bifida occulta
A nurse is collecting data from a child who has spina bifida occulta. Which of the following findings should the nurse expect?
- A. Flaccid paralysis of lower extremities
- B. Hip dislocation
- C. Hydrocephalus
- D. Dimple in sacral area
Correct Answer: D
Rationale: The correct answer is D: Dimple in sacral area. In spina bifida occulta, there is a small gap in the spine but no protrusion of the spinal cord or meninges. A dimple in the sacral area is a common physical finding. Flaccid paralysis of lower extremities (A) is more characteristic of myelomeningocele, not occulta. Hip dislocation (B) is not typically associated with spina bifida occulta. Hydrocephalus (C) is more commonly seen with myelomeningocele as well. The presence of a dimple in the sacral area is a key indicator of spina bifida occulta due to the incomplete closure of the spinal column.