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A nurse is holding an infant during a lumbar puncture for a suspicion of meningitis. The infant is in a sitting position with the buttocks at the edge of the table and the neck flexed, and the nurse is immobilizing the infant's arms and legs. Which assessment takes priority during the procedure?
- A. Circulation checks of the lower extremities
- B. Heart rate and crying pattern
- C. Chest expansion and diaphragm excursion
- D. Clarity of spinal fluid and level of consciousness
Correct Answer: C
Rationale: Chest expansion is critical due to the infant's position, which may limit breathing.
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The parents of a 5-month-old infant state that their infant seems to eat very little. Most of the food comes out of the infant's mouth and onto his clothes.
- A. "Give the baby a bottle of formula before solid food to assure adequate caloric intake."'
- B. "Stop the solid foods and try again when the baby is 12 months old."'
- C. "Put the cereal in a bottle and feed the baby through a nipple with a large hole."'
- D. "Place the food in the back of the baby's mouth using a long-handled spoon."'
Correct Answer: D
Rationale: The correct answer is D because at 5 months, infants are typically ready to start experimenting with solid foods. Placing the food in the back of the baby's mouth using a long-handled spoon helps prevent the baby from pushing the food out with their tongue reflex, allowing for more successful feeding. This method also encourages the baby to learn how to swallow solids properly. Choice A is incorrect as giving formula before solid food won't address the feeding issue. Choice B is incorrect as stopping solid foods until 12 months can hinder the baby's developmental milestones. Choice C is incorrect as feeding cereal in a bottle can increase the risk of choking and doesn't address the underlying issue of feeding difficulty.
The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:
- A. Needed brief oral and nasal suctioning.
- B. Required endotracheal intubation and bagging with a hand-held resuscitator.
- C. Was stillborn and required CPR.
- D. Required physical stimulation and supplemental oxygen.
Correct Answer: D
Rationale: The correct answer is D: Required physical stimulation and supplemental oxygen. The Apgar score assesses a newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 5 at one minute indicates the infant needed assistance, such as stimulation to breathe and oxygen support. The score of 7 at five minutes shows improvement but still requires some intervention. Choices A, B, and C are incorrect because they suggest more aggressive interventions that are not indicated based on the Apgar scores provided, as the infant's condition was not critical enough to warrant those actions.
In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.
A nurse is initiating a plan of care for a toddler who is hospitalized. Which of the following instructions is important to communicate to the nursing assistant?
- A. Have the toddler dress himself.
- B. Offer the toddler finger foods for snacks.
- C. Provide opportunities to share toys with others.
- D. Ask the child simple yes or no questions.
Correct Answer: B
Rationale: The correct answer is B: Offer the toddler finger foods for snacks. This instruction is important to communicate to the nursing assistant because toddlers are at risk for choking on certain foods due to their developing chewing and swallowing abilities. Finger foods are safer for toddlers to eat as they are easier to manage and reduce the risk of choking.
Other choices are incorrect because:
A: Having the toddler dress himself may not be appropriate as toddlers may need assistance and supervision due to their limited motor skills.
C: Providing opportunities to share toys with others is important for social development but is not as critical as ensuring the toddler's safety during meal times.
D: Asking the child simple yes or no questions is a good communication strategy but not as essential for the toddler's safety during snack times.
A nurse is discussing nutrition with an adolescent who is pregnant.
- A. "I told my daughter that any calories ingested are a source of energy and nutrition."'
- B. "I try to provide foods with an increased amount of calcium,protein and iron."'
- C. "I encourage between-meal snacks that are complex carbohydrates and fruits."'
- D. "I have planned meals and snacks for additional calories in the second and third trimester."'
Correct Answer: A
Rationale: Step 1: A is correct because it emphasizes the importance of calorie intake for energy and nutrition during pregnancy.
Step 2: Adolescents have higher calorie needs during pregnancy, making this advice crucial.
Step 3: B focuses on specific nutrients but doesn't address overall calorie intake.
Step 4: C mentions healthy snacks but doesn't emphasize the importance of calories.
Step 5: D mentions additional calories but lacks the focus on all calories being essential.
Step 6: A provides a comprehensive approach to nutrition during pregnancy, making it the correct choice.