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A nurse is preparing to take a rectal temperature on a 7-month-old infant. Which of the following should the nurse keep in mind when preparing to take the temperature?
- A. A well-lubricated thermometer tip should be inserted a maximum of 2.5 in into the rectum.
- B. A rectal temperature of 99.6° F is equal to an oral temperature of 97.7° F.
- C. Infants should have temperatures taken rectally for accuracy and thermoregulation.
- D. Mercury thermometers are the thermometers of choice to obtain the rectal temperature, holding it in place for 4 min.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The correct answer is B because rectal temperatures are typically 1.5-2°F higher than oral temperatures due to the body's core temperature being higher internally. This conversion is essential in accurately interpreting the infant's rectal temperature.
Summary of other choices:
A: Incorrect. The maximum insertion depth for a rectal thermometer in infants is 1 inch, not 2.5 inches.
C: Incorrect. Rectal temperatures are not the only accurate method for infants; axillary or temporal artery thermometers are also reliable.
D: Incorrect. Mercury thermometers are no longer recommended due to the risk of mercury exposure, and the time required to obtain a rectal temperature is typically shorter.
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Which of the following approaches is the most accurate way to measure the heart rate of a 10-month-old infant?
- A. "Apical"'
- B. "Radial"'
- C. "Ulna"'
- D. "Brachial"'
Correct Answer: A
Rationale: The correct answer is A: "Apical." This method involves placing the stethoscope over the apex of the heart to directly listen to the heart sounds. In infants, especially 10-month-olds, the apical pulse is more accurate as it allows for a direct assessment of the heart rate without interference from other factors like peripheral pulses. The apical pulse is easier to locate in infants due to their smaller chest size and thinner chest walls. Choices B, C, and D (Radial, Ulna, and Brachial) are incorrect for measuring heart rate in infants as they involve peripheral pulse sites which may not provide an accurate representation of the heart rate due to various factors like weak pulses or difficulty in palpating them accurately in infants.
A nurse is caring for a 7-year-old child who is admitted with an asthma exacerbation.
- A. "Monitoring oxygen saturation and respiratory rate daily."'
- B. "Identification and avoidance of factors that trigger symptoms."'
- C. "Monitoring peak flow measurements regularly."'
- D. "Positioning the client upright in a position of comfort."'
Correct Answer: B
Rationale: The correct answer is B because identifying and avoiding triggers helps prevent asthma exacerbations. This proactive approach addresses the root cause of the issue, promoting long-term management. Monitoring oxygen saturation, respiratory rate, and peak flow are important but reactive measures, not addressing the underlying triggers. Positioning upright aids breathing but does not prevent exacerbations.
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.
A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH). The physician orders magnesium sulfate. Which nursing intervention is important when administering this drug?
- A. Assess blood pressure and respiratory rate every fifteen minutes
- B. Monitor blood glucose levels every eight hours
- C. Evaluate for orthostatic hypotension when getting the client up to walk
- D. Observe for premature labor every shift
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate is a central nervous system depressant used to prevent seizures in PIH. It can cause respiratory depression and hypotension. Assessing blood pressure and respiratory rate every fifteen minutes is crucial to monitor for signs of magnesium toxicity and ensure the client's safety. Monitoring blood glucose levels (B) is not directly related to magnesium sulfate administration. Evaluating for orthostatic hypotension (C) and observing for premature labor (D) are not specific to the administration of magnesium sulfate in treating PIH.
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply).
- A. Heart Rate 154/min
- B. Axillary temperature 96.8 F
- C. Respiratory rate 58/min
- D. Length 43 cm (16.9in)
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
1. Heart rate of 154/min is expected in a newborn, indicating normal cardiac function.
2. Axillary temperature of 96.8 F is within the normal range for a newborn.
3. Respiratory rate of 58/min is expected due to the newborn's immature respiratory system.
4. Length of 43 cm (16.9 in) falls within the normal range for a newborn's size.
Incorrect choices are not applicable due to lack of details, but in general, incorrect options would have included values outside the normal range for a newborn's physical assessment.