Nokea
After clearing the airway of a newborn who is not in distress, what is the most important action to take next?
- A. Administer free-flow oxygen
- B. Clamp and cut the cord
- C. Keep the newborn warm
- D. Obtain an APGAR score
Correct Answer: C
Rationale: Keeping the newborn warm is crucial immediately after clearing the airway to prevent hypothermia, which can lead to complications in newborns. Administering free-flow oxygen is not necessary if the newborn is not in distress. Clamping and cutting the cord can be done after ensuring the newborn's warmth. Obtaining an APGAR score is important but can be done after ensuring the newborn is kept warm and stable.
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A child with diabetes insipidus is being treated with vasopressin. The nurse would assess the child closely for signs and symptoms of which condition?
- A. Syndrome of inappropriate antidiuretic hormone (SIADH)
- B. Thyroid storm
- C. Cushing syndrome
- D. Vitamin D toxicity
Correct Answer: A
Rationale: The correct answer is A: Syndrome of inappropriate antidiuretic hormone (SIADH). Vasopressin is a medication used to treat diabetes insipidus by increasing water reabsorption in the kidneys. However, an excessive dose of vasopressin can lead to water retention, causing SIADH, which is characterized by dilutional hyponatremia. Choices B, C, and D are incorrect. Thyroid storm is a severe form of hyperthyroidism characterized by increased metabolism and can lead to life-threatening complications. Cushing syndrome results from excess cortisol production and is characterized by weight gain, hypertension, and other features. Vitamin D toxicity occurs due to an overdose of vitamin D, leading to hypercalcemia and symptoms such as nausea, vomiting, and weakness.
The nurse is obtaining a health history from parents of a 4-month-old boy with congenital hypothyroidism. What would the nurse most likely assess?
- A. The child's growth is above normal for his age.
- B. The child is active and playful.
- C. The skin appears pink and healthy.
- D. It is difficult to keep the child awake.
Correct Answer: D
Rationale: The correct answer is D. Congenital hypothyroidism in infants often leads to lethargy and difficulty staying awake due to low thyroid hormone levels. Assessing the child's ability to stay awake is crucial in identifying signs of hypothyroidism. Choices A, B, and C are incorrect because above-normal growth, being active and playful, and having healthy-looking skin are not typical manifestations of congenital hypothyroidism. Instead, infants with hypothyroidism may exhibit poor weight gain, decreased activity, and dry, pale skin.
What is the priority nursing responsibility when a 3-year-old child in a crib is experiencing a tonic-clonic seizure with a clamped jaw?
- A. Apply restraints.
- B. Administer oxygen.
- C. Protect the child from self-injury.
- D. Insert a plastic airway in the child's mouth.
Correct Answer: C
Rationale: During a tonic-clonic seizure, the priority nursing responsibility is to protect the child from self-injury. Applying restraints (Choice A) can cause harm by restricting movement during the seizure. While administering oxygen (Choice B) may be necessary, it is not the immediate priority during an active seizure. Inserting a plastic airway (Choice D) is contraindicated as it can lead to injury and is not recommended during a seizure. Protecting the child from self-injury (Choice C) is crucial to prevent harm from uncontrolled movements and potential falls, ensuring the safety of the child.
A parent asks a nurse how to tell the difference between measles (rubeola) and German measles (rubella). What should the nurse tell the parent about rubeola that is different from rubella?
- A. High fever and Koplik spots
- B. Rash on the trunk with pruritus
- C. Nausea, vomiting, and abdominal cramps
- D. Characteristics of a cold, followed by a rash
Correct Answer: A
Rationale: Rubeola (measles) is characterized by a high fever and the presence of Koplik spots, which are not seen in rubella (German measles). Therefore, the correct answer is A. Choice B, rash on the trunk with pruritus, is more indicative of rubella rather than rubeola. Choice C, nausea, vomiting, and abdominal cramps, are not specific differentiating symptoms between rubeola and rubella. Choice D, characteristics of a cold followed by a rash, does not specifically distinguish between rubeola and rubella.
A child undergoes heart surgery to repair the defects associated with tetralogy of Fallot. What behavior is essential for the nurse to prevent postoperatively?
- A. Crying
- B. Coughing
- C. Straining at stool
- D. Unnecessary movement
Correct Answer: C
Rationale: The correct behavior that the nurse needs to prevent postoperatively is straining at stool. Straining at stool should be avoided as it can increase intrathoracic pressure, leading to stress on the surgical site. This stress can potentially compromise the surgical repair and increase the risk of complications. Crying, coughing, and unnecessary movement, although important to monitor postoperatively, do not directly impact the surgical site as significantly as straining at stool does. Therefore, the focus should be on preventing straining at stool to ensure the best postoperative outcome for the child.