Correct statement regarding congenital rubella syndrome (CRS) is
- A. CRS with vaccine-strain of virus has not been reported
- B. Re-infections during pregnancy do not result in CRS
- C. Administration of immune globulin immediately after exposure to a case during pregnancy is effective in preventing CRS
- D. Patent ductus arteriosus is the commonest manifestation of CRS
Correct Answer: A
Rationale: CRS with the vaccine-strain of the virus has not been reported, as the vaccine strain is attenuated and does not cause congenital infection.
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Sequelae of a complete posterior cord section between C3 and T1 include:
- A. Muscle fasciculation
- B. Loss of sensation below the lesion
- C. Loss of deep tendon reflexes
- D. Athetoid movements
Correct Answer: B
Rationale: A complete posterior cord section results in loss of sensation below the lesion due to damage to the sensory pathways. Motor functions may remain intact as the anterior cord is unaffected.
The following statements are true:
- A. Unexplained vaginal discharge in a 3-year-old might be a sign of sexual abuse
- B. Spiral fracture of femur is always non-accidental
- C. Retinal bleeding in a 3-month-old unconscious baby is a sign of 'shaken baby' syndrome
- D. Bruises on the elbows and knees in a 4-year-old are suggestive of physical abuse
Correct Answer: C
Rationale: Retinal bleeding in a 3-month-old unconscious baby is a sign of 'shaken baby' syndrome: Retinal bleeding in infants, especially with other signs of physical abuse, is a key indicator of 'shaken baby' syndrome.
The main risk factor for developing deep vein thrombosis is:
- A. Prolonged immobility
- B. Age
- C. Obesity
- D. Family history
Correct Answer: A
Rationale: Prolonged immobility, such as during long flights or post-surgery, is a significant risk factor for developing deep vein thrombosis (DVT).
An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?
- A. Auscultate for presence of bowel sounds.
- B. Monitor hemoglobin and hematocrit
- C. Encourage turning and deep breathing
- D. Administer IV antibiotics as prescribed.
Correct Answer: D
Rationale: Administering IV antibiotics promptly is critical to treat the infection and prevent complications in acute pyelonephritis.
The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. Which statement by the father leads the nurse to determine he understood the instructions?
- A. If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest.
- B. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body.
- C. If the baby turns blue, I will immediately put the baby upright in an infant seat.
- D. If the baby turns blue, I will put the baby in supine position with his head elevated.
Correct Answer: A
Rationale: In the event of a paroxysmal hypercyanotic or tet spell, the infant should be placed in a knee-chest position.
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