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After placing an infant with myelomeningocele in an isolette shortly after birth, which indicator should the nurse use as the best way to determine the effectiveness of this intervention?
- A. The partial pressure of arterial oxygen remains between 94 and 100 mm Hg.
- B. The axillary temperature remains between 97° and 98°F (36.1° and 36.7°C).
- C. The respiratory rate remains within normal limits.
- D. The heart rate remains stable.
Correct Answer: B
Rationale: The isolette maintains a stable thermal environment. Monitoring axillary temperature ensures the infant is normothermic, indicating the isolette's effectiveness.
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A child with celiac disease is at risk for which complication if the diet is not followed?
- A. Renal failure.
- B. Intestinal lymphoma.
- C. Pulmonary fibrosis.
- D. Cardiomyopathy.
Correct Answer: B
Rationale: Untreated celiac disease increases the risk of intestinal lymphoma due to chronic inflammation. Renal, pulmonary, or cardiac complications are not directly associated.
An 8-year-old child does well after infratentorial tumor removal and is transferred back to the pediatric unit. Although she had been told about having her head shaved, she becomes upset. After exploring the child's feelings, which action should the nurse take?
- A. Ask the child if she'd like to wear a hat.
- B. Reassure the child that her hair will grow back.
- C. Explain to the child's parents that her reaction is normal.
- D. Suggest that the parents buy the child a wig as a surprise.
Correct Answer: A
Rationale: Offering a hat empowers the child to cope with her appearance change, addressing her distress directly.
A mother brings her 18-month-old to the clinic because the child 'eats ashes, crayons, and paper.' Which of the following information about the toddler should the nurse assess first?
- A. Evidence of eruption of large teeth.
- B. Amount of attention from the mother.
- C. Any changes in the home environment.
- D. Intake of a soft, low-roughage diet.
Correct Answer: C
Rationale: Changes in the home environment may contribute to pica, which requires immediate assessment.
When teaching the child with scoliosis being treated with a Boston brace about exercises, the nurse explains that the exercises are performed primarily for which of the following purposes?
- A. To decrease back muscle spasms.
- B. To improve the brace's traction effect.
- C. To prevent spinal contractures.
- D. To strengthen the back and abdominal muscles.
Correct Answer: D
Rationale: Exercises for scoliosis in a Boston brace focus on strengthening back and abdominal muscles to support spinal alignment and improve posture.
Which of the following nursing diagnoses would be appropriate for the nurse to identify as a priority diagnosis for an infant just admitted to the hospital with a diagnosis of gastroenteritis?
- A. Pain related to repeated episodes of vomiting.
- B. Deficient fluid volume related to excessive losses from severe diarrhea.
- C. Impaired parenting related to infant's loss of feeding pattern.
- D. Impaired urinary elimination related to increased fluid intake.
Correct Answer: B
Rationale: Fluid loss from diarrhea is the most urgent concern in gastroenteritis.