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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.
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A 2-month-old infant who has just undergone cleft palate repair
A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?
- A. Keep the infant in a side-lying position.
- B. Remove elbow restraints while the infant is sleeping
- C. Administer pain medication around the clock for the first 72 hr.
- D. Feed the infant half-strength formula for the first 48 hr
Correct Answer: C,D
Rationale: Correct Answer: C, D
Rationale:
C: Administer pain medication around the clock for the first 72 hr to ensure adequate pain management post-cleft palate repair.
D: Feed the infant half-strength formula for the first 48 hr to prevent potential aspiration and promote healing.
Summary:
A: Keeping the infant in a side-lying position is not directly related to cleft palate repair care.
B: Removing elbow restraints while the infant is sleeping may increase the risk of self-injury.
E, F, G: No additional information provided, so cannot determine their relevance.
A newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery
A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?
- A. Promote maternal-infant bonding
- B. Provide age-appropriate stimulation.
- C. Educate the parents about the defect.
- D. Maintain integrity of the sac.
Correct Answer: D
Rationale: The correct answer is D: Maintain integrity of the sac. This is the priority goal because the newborn with myelomeningocele is at risk for infection and further damage if the sac is not properly cared for. By ensuring the sac is clean, covered, and protected, the nurse can help prevent complications such as meningitis. Promoting maternal-infant bonding (A) is important but not the priority at this time. Providing age-appropriate stimulation (B) is not as urgent as ensuring the sac's integrity. Educating the parents about the defect (C) is crucial for long-term care but not the immediate priority.
A child who has hemophilia
A nurse is reinforcing teaching about controlling a bleeding episode with a parent of a child who has hemophilia. Which of the following statements by the parent indicates a need for further teaching?
- A. I will elevate the affected area if possible.
- B. I will apply warm compresses over the site.
- C. I will have my child rest.
- D. I will promptly immobilize the involved area to relieve pain & decrease bleeding.
Correct Answer: B
Rationale: The correct answer is B because applying warm compresses can worsen bleeding in hemophilia by dilating blood vessels. Elevating the affected area helps reduce blood flow to the site, aiding in clot formation. Resting minimizes movement that could exacerbate bleeding. Promptly immobilizing the area helps reduce pain and prevent further bleeding. Therefore, the incorrect choice (B) contradicts the principles of managing bleeding in hemophilia.
An infant who has Tetralogy of Fallot and is easily fatigued when eating
A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?
- A. Overriding aorta
- B. Pulmonary stenosis
- C. Left ventricular hypertrophy
- D. Ventricular septal defect
Correct Answer: C
Rationale: The correct answer is C: Left ventricular hypertrophy is not present in Tetralogy of Fallot. In Tetralogy of Fallot, the four main defects are pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. Left ventricular hypertrophy is not part of the condition. The infant's fatigue during feeding is likely due to decreased oxygen levels in the blood caused by the pulmonary stenosis and right-to-left shunting at the ventricular septal defect. Choices A, B, and D are all components of Tetralogy of Fallot, making them incorrect options.
A toddler who has laryngotracheobronchitis
A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?
- A. Decreased stridor
- B. Increased restlessness
- C. Decreased heart rate
- D. Decreased temperature
Correct Answer: B
Rationale: The correct answer is B: Increased restlessness. Restlessness is a common sign of airway obstruction in toddlers with laryngotracheobronchitis. As the airway becomes more obstructed, the toddler may feel increasingly anxious and agitated, leading to increased restlessness. Monitoring for this sign is crucial as it indicates worsening respiratory distress and the need for prompt intervention.
Decreased stridor (choice A) is not indicative of airway obstruction in this condition, as stridor is a high-pitched sound heard on inspiration and can be present in both mild and severe cases of laryngotracheobronchitis. Decreased heart rate (choice C) and decreased temperature (choice D) are not typically associated with airway obstruction and are less relevant in this context.