Nokea
A nurse is caring for an infant with hypospadias. Which of the following is an expected finding?
- A. The meatal opening is on the dorsal surface of the penis.
- B. The urethral opening is on the underside of the penis.
- C. Fluid is present in the scrotal sac containing the testes.
- D. The testes are not palpable within the scrotal sac.
Correct Answer: B
Rationale: Hypospadias involves the urethral opening being located on the underside of the penis.
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The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate?
- A. Instruct the mother to breathe slowly because this is a sign of hyperventilation
- B. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions
- C. Turn the woman onto her left side to relieve pressure on the umbilical cord
- D. Reduce the oral and IV fluids to decrease circulatory overload
Correct Answer: C
Rationale: The correct answer is C: Turn the woman onto her left side to relieve pressure on the umbilical cord. Variable decelerations are associated with umbilical cord compression. Turning the woman onto her left side can help relieve pressure on the cord, improving fetal oxygenation. This position change is a non-invasive, quick intervention that can potentially resolve the variable decelerations.
Choice A is incorrect because variable decelerations are not typically associated with hyperventilation. Choice B is incorrect as decreasing Pitocin may not directly address the underlying cause of the variable decelerations. Choice D is incorrect because reducing fluids may not address the immediate concern of umbilical cord compression.
Which site is preferred for giving an IM injection to a newborn?
- A. Ventrogluteal
- B. Vastus lateralis
- C. Rectus femoris
- D. Dorsogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. The vastus lateralis muscle is preferred for IM injections in newborns due to its large muscle mass, minimal risk of injury to major blood vessels and nerves, and easy accessibility. It is also recommended by healthcare guidelines for infants. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of damaging nerves and blood vessels. The rectus femoris muscle is not typically used for IM injections in newborns as it is less accessible and has a higher risk of injury.
An 8-year-old child is admitted to a pediatric unit with a fractured femur and is placed in skeletal traction. Which of the following nursing interventions is the most appropriate?
- A. Position the weights securely against the foot of the bed.
- B. Provide small frequent high-fat meals to the child.
- C. Compare pulses on affected site to contralateral side.
- D. Provide diversional activities to minimize the child's movement.
Correct Answer: C
Rationale: The correct answer is C: Compare pulses on affected site to contralateral side. This is the most appropriate nursing intervention because it assesses for any circulatory compromise due to the skeletal traction. Checking pulses helps monitor perfusion distal to the fracture site and ensures early detection of any complications like compartment syndrome. Positioning the weights against the foot of the bed (A) is incorrect as it can cause uneven traction. Providing high-fat meals (B) and diversional activities (D) are irrelevant to the immediate care of the child's fracture.
During an outpatient clinic visit, a 13-year-old client is diagnosed with infectious mononucleosis. The nurse should expect which of the following to be included in the client's plan of care?
- A. Take acetaminophen (Tylenol) with codeine as prescribed for pain.
- B. Encourage gargling with warm water to alleviate pain.
- C. Start a short course of ampicillin.
- D. Encourage social activity to prevent depression.
Correct Answer: B
Rationale: The correct answer is B: Encourage gargling with warm water to alleviate pain. Gargling with warm water can help soothe a sore throat, a common symptom of infectious mononucleosis. Acetaminophen with codeine (A) is not typically recommended for mononucleosis pain management in children due to the risk of respiratory depression. Starting a short course of ampicillin (C) is contraindicated in mononucleosis as it can cause a rash. Encouraging social activity (D) may not be appropriate as the client may need rest to recover.
For a pregnant adolescent who is anemic, which foods should the nurse include in the client's dietary plan to increase iron levels?
- A. Milk and fish
- B. Chicken and cottage cheese
- C. Orange juice and apricots
- D. Pickles and peanut butter sandwiches
Correct Answer: C
Rationale: The correct answer is C: Orange juice and apricots. Orange juice is a good source of Vitamin C, which enhances iron absorption. Apricots are high in iron, helping to increase iron levels in the body. Milk and fish (choice A) contain little iron. Chicken and cottage cheese (choice B) are not significant sources of iron. Pickles and peanut butter sandwiches (choice D) lack iron and Vitamin C.