Nokea
An infant with hypertrophic pyloric stenosis (HPS) is admitted to the pediatric unit. What does the nurse expect when palpating the infant's abdomen?
- A. A distended colon
- B. Marked tenderness around the umbilicus
- C. An olive-sized mass in the right upper quadrant
- D. Rhythmic peristaltic waves in the lower abdomen
Correct Answer: C
Rationale: When palpating the abdomen of an infant with hypertrophic pyloric stenosis (HPS), the nurse would expect to feel an olive-sized mass in the right upper quadrant. This finding is characteristic of HPS due to the hypertrophied pylorus muscle. Choices A, B, and D are incorrect. A distended colon is not typically associated with HPS. Marked tenderness around the umbilicus is not a specific finding of HPS. Rhythmic peristaltic waves in the lower abdomen are not expected in HPS, as the condition primarily affects the pylorus region of the stomach.
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When you attempt to assess a 22-year-old woman who has been sexually assaulted, and she orders you not to touch her, your most appropriate initial action should be to
- A. ask the patient to sign a release form
- B. ask a female EMT-B to attempt to assess the patient
- C. explain to the patient that she must be examined
- D. transport the patient without performing an assessment
Correct Answer: B
Rationale: In cases of sexual assault, it is crucial to prioritize the patient's emotional and physical comfort. Asking a female EMT-B to attempt the assessment is the most appropriate initial action as it respects the patient's need for privacy and comfort. Asking the patient to sign a release form (Choice A) is not the immediate concern when the patient's well-being and comfort are at stake. Explaining to the patient that she must be examined (Choice C) disregards her autonomy and can worsen the trauma she is experiencing. Transporting the patient without performing an assessment (Choice D) neglects the necessary evaluation and potentially vital care that she may require.
A newborn is diagnosed with metatarsus adductus. The parents ask the nurse how this occurred. Which response by the nurse would be most appropriate?
- A. This condition is due to a genetic defect in the bones.
- B. It's most likely from how the baby was positioned in utero.
- C. They really don't know what causes this condition.
- D. There is probably an underlying deformity of the baby's hip.
Correct Answer: B
Rationale: Metatarsus adductus is a condition where the front part of the foot is turned inward. It is often caused by the baby's position in the womb, leading to pressure on the foot during fetal development. Choice A is incorrect as metatarsus adductus is not primarily caused by a genetic defect in the bones. Choice C is incorrect as the cause of metatarsus adductus is known to be related to intrauterine positioning. Choice D is incorrect as metatarsus adductus specifically pertains to the foot and not the hip.
After a cardiac catheterization, what is the priority nursing care for a 3-year-old child?
- A. Encouraging early ambulation
- B. Monitoring the site for bleeding
- C. Restricting fluids until the blood pressure is stabilized
- D. Comparing the blood pressure of both lower extremities
Correct Answer: B
Rationale: The priority nursing care after a cardiac catheterization in a 3-year-old is to monitor the site for bleeding. This is essential to promptly detect and manage any potential complications, such as hematoma or hemorrhage. Encouraging early ambulation, as mentioned in choice A, may not be safe immediately post-procedure and should be guided by the healthcare provider's instructions. Restricting fluids until blood pressure is stabilized, as in choice C, is not typically necessary after a cardiac catheterization. Comparing blood pressure in both lower extremities, as in choice D, is not the priority immediate nursing care following this procedure.
At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. The woman states that her contractions are occurring every 4 to 5 minutes and lasting approximately 30 seconds each. Which of the following questions would be most appropriate to ask at this point?
- A. Has your bag of waters broken yet?
- B. Have you had regular prenatal care?
- C. At how many weeks gestation are you?
- D. How many other children do you have?
Correct Answer: C
Rationale: In this scenario, asking about the gestational age is crucial as it helps determine the stage of labor and potential complications. Knowing the number of weeks of gestation can guide the healthcare provider in assessing the progress of labor and making decisions about the care of both the mother and the baby. Choices A, B, and D are not as relevant in this urgent situation. While knowing if the bag of waters has broken is important for assessing the progress of labor, determining gestational age is more critical at this point. Asking about regular prenatal care or the number of other children does not provide immediate information necessary for managing the current situation.
The healthcare provider closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication?
- A. infection
- B. hypertension
- C. encephalopathy
- D. edema
Correct Answer: A
Rationale: Monitoring the temperature of a child with minimal change nephrotic syndrome is crucial for detecting early signs of infection, a common complication in this condition. In nephrotic syndrome, the child's immune system is compromised, making them more susceptible to infections. Monitoring for fever or any changes in temperature can help healthcare providers intervene promptly to prevent further complications. Hypertension (choice B) is not typically associated with minimal change nephrotic syndrome. Encephalopathy (choice C) refers to brain dysfunction and is not a common complication of nephrotic syndrome. Edema (choice D) is a primary manifestation of nephrotic syndrome but is not typically monitored through temperature assessment.