Nokea
Because the burned child is confined to bed, the nurse assesses for footdrop. Which nursing action best prevents call the development of footdrop?
- A. Apply braces to the feet and ankles.
- B. Keep the child in the side-lying position.
- C. Keep sheets tucked in at the foot of the bed.
- D. Rest the child's feet against a footboard.
Correct Answer: D
Rationale: Resting the child's feet against a footboard maintains a neutral position, preventing plantar flexion and footdrop during prolonged bed rest.
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The nurse would expect to withhold penicillin V (Pen-Vee-K) and notify the physician if the child had a previous allergic reaction to a medication from which drug group?
- A. Aminoglycosides
- B. Cephalosporins
- C. Macrolides
- D. Sulfonamides
Correct Answer: B
Rationale: Penicillin V is a penicillin antibiotic, and cephalosporins have a similar beta-lactam structure, which can lead to cross-reactivity in patients with penicillin allergies. Withholding penicillin and notifying the physician is necessary if the child has a cephalosporin allergy.
The nurse is caring for the newborn infant. The nurse should prepare to assess the newborn’s anterior fontanel by which method?
- A. Lay the infant on his or her back.
- B. Stimulate the infant to cry strongly.
- C. Feel near the parietal and occipital bones.
- D. Place the infant in a sitting position.
Correct Answer: D
Rationale: The anterior fontanel is assessed with the infant in a sitting position (45°–90°) to evaluate size and abnormalities. Supine positioning or crying may cause bulging and parietal/occipital bones locate the posterior fontanel.
19 years old primigravida comes in emergency at 32 weeks of gestation. She is complaining of blurring of vision,gross edema. On examination her B.P is 170/115 mm Hg. What is the most likely diagnosis:
- A. Hypertension.
- B. Renal disease.
- C. Eclampsia.
- D. Preeclampsia.
- E. Thyroid disease.
Correct Answer: D
Rationale: Preeclampsia is characterized by hypertension (BP ≥140/90 mmHg) after 20 weeks gestation with symptoms like edema and visual disturbances. Eclampsia involves seizures which are not mentioned. Hypertension alone lacks other symptoms and renal or thyroid disease are less likely without specific indicators.
The nurse is caring for a 30-year-old,single female who delivered a term newborn. What is the best way for the nurse to assess the impact of the newborn on the client’s lifestyle?
- A. Observe how the client interacts with her hospital visitors.
- B. Review the prenatal record for clues about the client’s lifestyle.
- C. Ask the client what plans she has made for newborn care at home.
- D. Observe the relationship between the client and her newborn’s father.
Correct Answer: C
Rationale: Open-ended questions about newborn care plans encourage sharing of lifestyle adjustments especially for single parents. Visitors prenatal records or father involvement are less direct.
A 23 years old primigravida comes in labour room for induction of labour. Cervix is closed and 3 cm long. Which of the following medicine will be given to her for cervical ripening?
- A. Methergin.
- B. Salbutamol.
- C. Prostaglandin E2.
- D. Paracetamol.
- E. Methyldopa.
Correct Answer: C
Rationale: Prostaglandin E2 is used for cervical ripening in induction of labor as it softens and dilates the cervix. Other medications are not indicated for this purpose.