Nokea
After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the father states which of the following?
- A. There is no rectal opening for stool to pass.
- B. There is a tube between the trachea and esophagus.
- C. The nerves at the end of the large colon are missing.
- D. The muscle below the stomach is too tight.
Correct Answer: C
Rationale: Hirschsprung's disease is characterized by absent nerve cells in the distal colon.
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The physician is able to reduce an infant's hernia and schedules the infant for a herniorrhaphy in 2 days. The mother asks the nurse why the surgery is not performed now. Which of the following responses indicates that the nurse understands the rationale for delaying the surgery?
- A. Delaying the surgery ensures that your infant will receive the proper preoperative preparation.
- B. The infant can take nothing by mouth for at least 24 hours before the surgery.
- C. Waiting these 2 days helps to allow any edema and inflammation in the area to subside.
- D. Your infant needs to wear a truss for at least 24 hours before any surgery can be attempted.
Correct Answer: C
Rationale: Delaying surgery allows edema and inflammation to decrease, improving surgical outcomes.
When teaching the family of an older infant who has had a hip spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar?
- A. It can be adjusted to a position of comfort.
- B. It is used to lift the child.
- C. It adds strength to the cast.
- D. It is necessary to turn the child.
Correct Answer: C
Rationale: The abduction stabilizer bar maintains the legs in abduction to promote hip joint stability and adds structural strength to the cast.
Which of the following breathing rates should the nurse use when performing rescue breathing during cardiopulmonary resuscitation for a 5-year-old?
- A. 10 breaths/minute.
- B. 12 breaths/minute.
- C. 15 breaths/minute.
- D. 20 breaths/minute.
Correct Answer: B
Rationale: For a 5-year-old, the recommended rescue breathing rate during CPR is 12 to 20 breaths per minute, with 12 breaths/minute being appropriate to avoid hyperventilation.
While assessing the penis of a child who has had surgery for repair of a hypospadias, the nurse observes the appearance of the penis. The nurse should report which aspect to the surgeon?
- A. Swollen.
- B. Dusky blue at the tip.
- C. Somewhat misshapen.
- D. Pink.
Correct Answer: B
Rationale: Dusky coloration may indicate compromised circulation.
A 10-year-old has 5 lb of Buck's extension traction on his left leg. The nurse should assess the child for which of the following? Select all that apply.
- A. Dryness of the skin, by removing the foam wraps and boot.
- B. Alignment of the shoulder, hips, and knees.
- C. Frayed rope near pulleys.
- D. Correct amount of traction weight on fracture.
- E. Pressure on the coccyx.
Correct Answer: B,C,D,E
Rationale: The nurse should check alignment, rope condition, weight accuracy, and pressure points to ensure effective and safe traction.