Nokea
After teaching the parents of a neonate diagnosed with a tracheoesophageal fistula (TEF) about this anomaly, the nurse determines that the teaching was successful when the father describes the condition as which of the following?
- A. The muscle below the stomach is too tight, causing the baby to vomit forcefully.
- B. There is a blind upper pouch and an opening from the esophagus into the airway.
- C. The lower bowel is lacking certain nerves to allow normal function.
- D. A part of the bowel is on the outside without anything covering it.
Correct Answer: B
Rationale: TEF involves a blind esophageal pouch and a fistula connecting the esophagus to the trachea, as described.
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When assessing the development of a 15-month-old child with cerebral palsy, which of the following milestones should the nurse expect a toddler of this age to have achieved?
- A. Walking up steps.
- B. Using a spoon.
- C. Copying a circle.
- D. Putting a block in cup.
Correct Answer: D
Rationale: A 15-month-old typically can put a block in a cup, a milestone achievable even with motor challenges from cerebral palsy, unlike the other options which require more advanced skills.
After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which of the following?
- A. Decreases pain at the surgical site.
- B. Keeps the new urethra from closing.
- C. Measures his urine correctly.
- D. Prevents bladder spasms.
Correct Answer: B
Rationale: The catheter keeps the urethra open.
A parent of a child with a moderate head injury asks the nurse, 'How will you know if my child is getting worse?' The nurse should tell the parents that the best indicator of the child's brain function is:
- A. The vital signs.
- B. Level of consciousness.
- C. Reactions of the pupils.
- D. Motor strength.
Correct Answer: B
Rationale: Level of consciousness is the most sensitive indicator of brain function, reflecting changes in neurological status.
When teaching the mother of an infant who has undergone surgical repair of a cleft lip how to care for the suture line, the nurse demonstrates how to remove formula and drainage. Which of the following solutions should the nurse use?
- A. Mouthwash.
- B. Povidone-iodine (Betadine) solution.
- C. A mild antiseptic solution.
- D. Half-strength hydrogen peroxide.
Correct Answer: D
Rationale: Half-strength hydrogen peroxide is gentle and effective for cleaning the suture line without irritating the delicate tissue.
Which of the following initial physical findings indicate the development of carditis in a child with rheumatic fever?
- A. Heart murmur.
- B. Low blood pressure.
- C. Irregular pulse.
- D. Anterior chest wall pain.
Correct Answer: A
Rationale: A heart murmur is a hallmark of carditis in rheumatic fever, indicating valvular involvement. Other findings may occur but are less specific.