Nokea
Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:
- A. A third heart sound
- B. A diastolic murmur
- C. Pulse pressure difference between the upper extremities
- D. Diminished or absent femoral pulses
Correct Answer: D
Rationale: S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. Pulse pressure differences of >20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate-sized cuffs. Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta.
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The client is diagnosed with a urinary tract infection. Which instruction should the nurse include in the discharge teaching?
- A. Limit fluid intake to reduce bladder irritation.'
- B. Take all prescribed antibiotics as directed.'
- C. Avoid sexual activity permanently.'
- D. Use heating pads to relieve discomfort.'
Correct Answer: B
Rationale: Completing the full course of antibiotics is essential to eradicate the infection and prevent resistance in a urinary tract infection. Fluid intake should increase, sexual activity can resume after treatment, and heating pads may not be advised.
In teaching the client about proper umbilical cord care, the nurse recommends that:
- A. Petrolatum be placed around the cord after the sponge bath
- B. A belly binder be applied to prevent umbilical hernia
- C. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage
- D. The cord clamp be left on until the cord stump separates
Correct Answer: C
Rationale: Petrolatum does not allow the cord to dry and will encourage infection. Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. Frequent applications of alcohol will facilitate drying and discourage infection. The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.
An amniocentesis at 32 weeks gestation reveals that a multigravida with diabetes has an L/S ratio of 1:1 with the presence of phosphatidylglycerol. Based on the amniocentesis,the nurse knows that if delivered now:
- A. The newborn is at low risk for congenital anomalies.
- B. The newborn is at high risk for intrauterine growth retardation.
- C. The newborn is at high risk for respiratory distress syndrome.
- D. The newborn is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 at 32 weeks indicates immature fetal lungs increasing the risk of respiratory distress syndrome (RDS) if delivered now. Phosphatidylglycerol presence is positive but does not fully mitigate RDS risk. The other risks are not directly related to the L/S ratio.
A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
- A. 5 mg
- B. 0.5 mg
- C. 0.05 mg
- D. 20 mg
Correct Answer: A
Rationale: 1 mg = 0.1 mL, then 0.5 mL X = 5 mg.
Which toys are suited to the developmental skills of the 2-3 year old?
- A. Soap bubbles
- B. Skates
- C. Riding toys
- D. Bicycle
- E. Talking toys
Correct Answer: A, C, E
Rationale: For 2-3-year-olds, soap bubbles (A), riding toys (C), and talking toys (E) match gross motor and imaginative play skills. Skates (B) and bicycles (D) require advanced coordination.