Nokea
An 8-year-old child is admitted to a pediatric unit with a fractured femur and is placed in skeletal traction. Which of the following nursing interventions is the most appropriate?
- A. Position the weights securely against the foot of the bed.
- B. Provide small frequent high-fat meals to the child.
- C. Compare pulses on affected site to contralateral side.
- D. Provide diversional activities to minimize the child's movement.
Correct Answer: C
Rationale: The correct answer is C: Compare pulses on affected site to contralateral side. This is the most appropriate nursing intervention because it assesses for any circulatory compromise due to the skeletal traction. Checking pulses helps monitor perfusion distal to the fracture site and ensures early detection of any complications like compartment syndrome. Positioning the weights against the foot of the bed (A) is incorrect as it can cause uneven traction. Providing high-fat meals (B) and diversional activities (D) are irrelevant to the immediate care of the child's fracture.
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A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is given a half an hour before delivery, which effect will the medication have on the infant?
- A. It will cause the infant's blood sugar to fall.
- B. It will cause the infant's respiratory rate to decrease.
- C. It will cause the infant's heart rate to increase.
- D. It will cause the infant's movements to be hyperactive.
Correct Answer: B
Rationale: The correct answer is B: It will cause the infant's respiratory rate to decrease. Narcotic analgesics can cross the placenta and affect the baby. These medications can depress the respiratory drive of the newborn, leading to decreased respiratory rate. This effect is particularly pronounced if the narcotic is given shortly before delivery when the drug levels in the infant's system are highest. The other choices are incorrect because: A) Narcotics are not known to directly affect blood sugar levels in infants. C) Narcotics typically cause a decrease, rather than an increase, in heart rate. D) Narcotics are more likely to cause sedation and decreased movements rather than hyperactivity in newborns.
A client in active labor receives a regional anesthetic. Which is the main purpose of regional anesthetics?
- A. To relieve pain by decreasing the client's level of consciousness
- B. To provide general loss of sensation by blocking sensory nerves to an area
- C. To provide pain relief by blocking descending impulses from the central nervous system
- D. To relieve pain by decreasing the perception of pain leading to the pain centers in the brain
Correct Answer: B
Rationale: The correct answer is B: To provide general loss of sensation by blocking sensory nerves to an area. Regional anesthetics work by blocking specific nerve pathways in a targeted area, leading to loss of sensation while maintaining consciousness. This is ideal for laboring clients as it allows pain relief without affecting consciousness or motor function. Choice A is incorrect as regional anesthetics do not aim to decrease consciousness. Choice C is incorrect as regional anesthetics block sensory nerves locally, not descending impulses. Choice D is incorrect as the goal is to block sensation locally, not perception in the brain.
A nurse is reinforcing teaching with the parents of an infant diagnosed with recurrent otitis media. Which of the following is appropriate teaching to include?
- A. Give the child an over-the-counter antihistamine when the symptoms begin.
- B. Hold the child in an upright position while feeding.
- C. Talk with the primary health care provider about performing a tonsillectomy.
- D. Apply a warm compress over the affected ear to provide comfort.
Correct Answer: B
Rationale: The correct answer is B: Hold the child in an upright position while feeding. This is important because feeding the infant in an upright position can help prevent reflux of milk into the Eustachian tube, reducing the risk of otitis media. This position helps to promote proper drainage and ventilation of the middle ear, decreasing the likelihood of infection.
Incorrect answers:
A: Giving the child an over-the-counter antihistamine is not appropriate for otitis media, as it is typically caused by bacterial infection, not allergies.
C: Tonsillectomy is not a first-line treatment for otitis media. It is usually considered if the child has recurrent tonsillitis, not otitis media.
D: Applying a warm compress over the affected ear may provide comfort but does not address the underlying cause or prevention of otitis media.
A nurse is caring for a child with measles.
- A. "Provide diversional activities such as video games."'
- B. "Maintain isolation for 48 hr after the rash resolves."'
- C. "Keep the child warm with adequate undergarments and bedding."'
- D. "Administer vitamin A supplements as prescribed."'
Correct Answer: D
Rationale: The correct answer is D because administering vitamin A supplements is a standard treatment for measles to reduce complications and improve recovery. Vitamin A deficiency is common in children with measles, and supplementation can help boost the immune system and reduce the severity of the illness. Providing diversional activities (choice A) may be suitable but does not directly address the medical needs of the child. Maintaining isolation (choice B) is important but typically lasts until 4 days after rash onset, not just 48 hours after rash resolution. Keeping the child warm (choice C) is a general comfort measure and may not directly impact measles treatment.
A 27-week gestation infant is taken to a newborn intensive care unit 150 miles away. Initially, which emotion should the nurse expect the mother to display after the transfer?
- A. Denial
- B. Frustration
- C. Guilt
- D. Anger
Correct Answer: C
Rationale: The correct answer is C: Guilt. The mother may feel responsible for the premature birth and subsequent transfer, leading to feelings of guilt. This is a common emotional response in such situations. Denial (A), frustration (B), and anger (D) may also be present, but guilt is the most likely initial emotion due to the perceived connection between the mother and the baby's health.