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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.
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A nurse is caring for a 14-year-old child with appendicitis who has a pain rating of 8 on a scale of 1 to 10.
- A. "Continue with the pain assessment."'
- B. "Take the child's vital signs."'
- C. "Notify the primary care provider."'
- D. "Auscultate the child's bowel sounds."'
Correct Answer: C
Rationale: The correct answer is C, "Notify the primary care provider." This is because a pain rating of 8 in a child with appendicitis indicates severe pain that may require immediate medical intervention. The primary care provider should be informed promptly to assess the situation and determine the appropriate course of action, which may include pain management or surgical intervention. Taking vital signs (choice B) and auscultating bowel sounds (choice D) are important assessments but do not address the urgency of the situation. Continuing with the pain assessment (choice A) may delay necessary interventions.
A postterm infant is delivered by cesarean section because of fetal distress and meconium-stained amniotic fluid. The nursery nurse frequently monitors the baby's respiratory rate, observing for tachypnea. Which is the reason for the nurse's actions? The infant may:
- A. experience respiratory depression from the medications used during delivery
- B. develop meconium aspiration pneumonia
- C. have an elevated temperature
- D. have a pneumothorax related to delivery
Correct Answer: B
Rationale: The correct answer is B: develop meconium aspiration pneumonia. Meconium-stained amniotic fluid can lead to the infant inhaling meconium, which can cause blockage and inflammation in the airways, leading to meconium aspiration pneumonia. This can result in respiratory distress, tachypnea, and potential complications like respiratory failure. The nurse monitors the respiratory rate to detect any signs of respiratory distress early on.
Incorrect choices:
A: Respiratory depression from medications used during delivery is less likely to be the cause of tachypnea in this scenario.
C: Elevated temperature is not directly related to meconium aspiration pneumonia or respiratory distress in this case.
D: A pneumothorax related to delivery is possible but less likely than meconium aspiration pneumonia as the cause of tachypnea in this case.
A new mother receives instructions about care of her newborn son's circumcision. Which statement made by the mother indicates that further teaching is needed?
- A. I will call the doctor if my baby's penis starts to bleed.
- B. I should wash off any yellowish mucous on my baby's penis.
- C. I will put vaseline on his penis every time I change his diaper.
- D. I should give my baby a sponge bath for the first week.
Correct Answer: B
Rationale: The correct answer is B. Washing off yellowish mucous is not recommended as it may be a normal part of the healing process after circumcision. The yellowish mucous is likely to be a scab or healing tissue, and washing it off could interfere with the healing process or cause infection. It is essential to let it fall off naturally. Choices A, C, and D are correct because calling the doctor for bleeding, applying vaseline for protection, and giving a sponge bath for hygiene are appropriate post-circumcision care.
What is the main cause of mastitis in the postpartum client?
- A. Poor breastfeeding technique
- B. Inadequate hand washing
- C. Systemic maternal infection
- D. Prolonged nursing
Correct Answer: A
Rationale: The correct answer is A: Poor breastfeeding technique. Mastitis in postpartum clients is commonly caused by milk stasis due to inadequate milk removal, which can result from poor breastfeeding technique such as improper latch or infrequent feedings. This leads to inflammation and infection. Inadequate hand washing (B) is important for preventing infection but not the main cause of mastitis. Systemic maternal infection (C) may contribute but is not the primary cause. Prolonged nursing (D) can actually help prevent mastitis by promoting milk flow.
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.