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A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings?
- A. Increase in appetite
- B. Tugging on the affected ear lobe
- C. Erythema and edema of the affected auricle
- D. Bluish-green discharge from the ear canal
Correct Answer: B
Rationale: Increase in appetite: Otitis media, an infection or inflammation of the middle ear, typically causes discomfort and pain in infants. As a result, they may experience a decrease in appetite rather than an increase. Tugging on the affected ear lobe: Tugging or pulling on the affected ear lobe is a common sign of ear pain in infants with otitis media. It occurs because the pain from the middle ear extends to the outer ear canal. Erythema and edema of the affected auricle: Otitis media primarily affects the middle ear, so erythema (redness) and edema (swelling) are not typically observed on the outer ear (auricle). Instead, these symptoms are more commonly seen in external ear infections, such as otitis externa. Bluish-green discharge from the ear canal: Bluish-green discharge from the ear canal is not a typical finding in otitis media. It may suggest a secondary bacterial infection or another underlying condition, but it is not a characteristic feature of otitis media.
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A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
- A. Move the child into a side-lying position.
- B. Place a pillow under the child's head.
- C. Time the seizure.
- D. Remove the child's eyeglasses.
Correct Answer: A
Rationale: Move the child into a side-lying position: This action is crucial during a seizure with vomiting to prevent aspiration. Placing the child on their side helps ensure that any vomit can easily exit the mouth and reduces the risk of choking or aspiration into the lungs. Place a pillow under the child's head: While providing comfort is important, it is not the priority during a seizure with vomiting. Placing a pillow under the child's head might elevate the head slightly, but it doesn't address the risk of aspiration, which is the primary concern. Time the seizure: Timing the seizure is important for documentation and to monitor the duration of the seizure. However, it is not the priority during the active phase of the seizure, especially when vomiting is occurring. Remove the child's eyeglasses: Removing the child's eyeglasses is not a priority during a seizure with vomiting. While it's important to prevent injury, particularly to the eyes, during a seizure, the immediate concern is addressing the risk of aspiration caused by vomiting.
A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect?
- A. Projectile vomiting
- B. Metabolic acidosis
- C. Effortless regurgitation
- D. Distended abdomen
Correct Answer: A
Rationale: Projectile vomiting is a classic symptom of pyloric stenosis in infants. It typically occurs within 30 minutes of feeding and is forceful, often projecting several feet away from the infant. This occurs due to the obstruction at the pyloric sphincter, leading to the stomach forcefully emptying its contents. Metabolic acidosis is not a typical finding associated with pyloric stenosis. Pyloric stenosis leads to vomiting, which can result in dehydration and electrolyte imbalances, but it typically does not cause metabolic acidosis directly. Effortless regurgitation is not a characteristic finding of pyloric stenosis. In pyloric stenosis, vomiting is forceful and projectile, rather than a passive regurgitation of stomach contents. A distended abdomen can be a finding in pyloric stenosis. The obstruction at the pyloric sphincter can lead to gastric retention, causing the stomach to become distended over time. However, it's important to note that not all infants with pyloric stenosis will present with a visibly distended abdomen.
A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?
- A. Place new linen on the client's bed every other day.
- B. Change gloves between sites when providing wound care to multiple wounds.
- C. Change the dressing on infected wounds first.
- D. Monitor vital signs every 4 hr.
Correct Answer: B
Rationale: Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.
A child is diagnosed with Wilms' tumor. During assessment, the nurse in charge expects to detect:
- A. Gross hematuria
- B. Dysuria
- C. An abdominal mass
- D. Nausea and Vomiting
Correct Answer: C
Rationale: Gross hematuria: Gross hematuria refers to visible blood in the urine, which can present as pink, red, or cola-colored urine. While hematuria can be associated with various kidney conditions, including Wilms' tumor, it is not a consistent or defining symptom of this specific tumor. Additionally, because the tumor is typically confined within the kidney and does not usually invade the urinary tract, gross hematuria might not always be present. Dysuria: Dysuria is the medical term for painful or difficult urination. It is not a typical symptom of Wilms' tumor, as this tumor primarily affects the kidney and may not directly affect the urinary tract in a way that causes painful urination. An abdominal mass: This is the correct answer. Wilms' tumor often presents as a palpable abdominal mass, which may be felt during physical examination. The mass is usually firm, non-tender, and confined to one side of the abdomen. Detection of an abdominal mass should prompt further diagnostic evaluation to confirm the diagnosis and plan appropriate treatment. Nausea and vomiting: While some children with Wilms' tumor may experience nausea and vomiting, these symptoms are nonspecific and can be caused by various conditions. They are not considered characteristic or defining features of Wilms' tumor. The presence of nausea and vomiting would prompt further assessment to determine the underlying cause.
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Change to cloth diapers until the skin is healed.
- B. Use a moisturizer to wipe urine from the skin.
- C. Apply a light layer of talcum powder with each diaper change.
- D. Expose the excoriated area to hot air frequently.
Correct Answer: B
Rationale: While some parents may prefer cloth diapers, they can retain moisture and irritants. Disposable diapers with good absorbency are often preferred in managing diaper dermatitis. Using a gentle moisturizer to clean the skin can help protect the infant's skin and maintain its barrier function, especially in cases of diaper dermatitis. Moisturizers help soothe and heal the affected area by providing hydration and protection. Talcum powder is not recommended due to the risk of inhalation, which can cause respiratory issues. Additionally, powders can clump and worsen skin irritation. Exposing the skin to hot air can dry out the skin and worsen irritation. It's better to allow the area to air-dry naturally or use a cool blow dryer on a low setting.