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A one-month-old patient, who has developmental dysplasia of the hip, is placed in a hip spica cast. The patient's mother expresses the desire to continue breastfeeding. What is the pediatric nurse's best response?
- A. After breastfeeding, hold your baby upright for 45 minutes.
- B. Due to the weight of the cast, breastfeeding is not encouraged. I recommend that you bottle-feed.
- C. Breastfeeding can continue without significant changes; ensure proper positioning to accommodate the cast.
- D. none of the above.
Correct Answer: C
Rationale: Breastfeeding can continue even with a hip spica cast, but proper positioning is essential to ensure comfort for both the infant and the mother.
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Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, "Why?" Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?
- A. Increased peristalsis
- B. Coughing
- C. Pneumonia
- D. Wound healing  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET K
Correct Answer: C
Rationale: Early postoperative ambulation is important for preventing complications such as pneumonia. When a patient remains immobile for an extended period after surgery, they are at an increased risk of developing pneumonia due to decreased lung expansion and secretions pooling in the lungs. Ambulation helps improve lung function, promote better oxygenation, and prevent respiratory complications like pneumonia. In contrast, increased peristalsis helps prevent constipation, coughing helps prevent respiratory complications as well, and wound healing is not directly related to the need for early postoperative ambulation.
Which discharge instruction for a child with encopresis should the nurse question?
- A. Limit milk intake.
- B. Obtain a complete dietary log.
- C. Follow up with a child psychologist.
- D. Offer a diet high in protein.
Correct Answer: D
Rationale: A high-protein diet can worsen constipation; a high-fiber, balanced diet is preferable.
Where is the best place to observe for the presence of petechiae in dark-skinned individuals?
- A. Face
- B. Buttocks TestBankWorld.org
- C. Oral mucosa
- D. Palms and soles
Correct Answer: C
Rationale: Petechiae are small, pinpoint, red or purple spots on the skin caused by bleeding into the skin. In dark-skinned individuals, it can be challenging to visualize petechiae due to the pigmentation of the skin. However, one of the best places to observe for the presence of petechiae in dark-skinned individuals is the oral mucosa, specifically the inner lining of the mouth. The oral mucosa is usually lighter in color compared to the skin, making it easier to identify petechiae in this area. Palms and soles may also be a good place to observe for petechiae, but the oral mucosa is typically the preferred site for examination in dark-skinned individuals.
Which of the ff is a nursing intervention when assessing clients with hypertension?
- A. The nurse takes the temperature when the client is in a standing, sitting, and then supine position
- B. The nurses teaches the client about non pharmacologic and pharmacologic methods for restoring BP
- C. The nurse takes BP in both arms when the client is in a standing, sitting, and then supine position
- D. The nurse weighs the client each morning
Correct Answer: B
Rationale: The nursing intervention of teaching the client about non-pharmacologic and pharmacologic methods for restoring blood pressure is crucial in managing hypertension. Education empowers the client to actively participate in their care and make informed decisions regarding lifestyle changes, medication adherence, and other interventions to control their blood pressure levels. By providing education on interventions such as dietary modifications, exercise, stress management, and medication use, the nurse helps the client develop a comprehensive plan to manage hypertension effectively and improve their overall health outcomes.
In embryonic period, all are true EXCEPT
- A. formation of ectoderm by 8 days
- B. formation of mesoderm by 10 weeks
- C. formation of endoderm by 3 cm crown-rump length
- D. formation of human embryo is about 6 weeks
Correct Answer: D
Rationale: The formation of the human embryo is completed by 8 weeks, not 6 weeks.