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If the child develops shortness of breath when ambulating to the bathroom in the hospital, which intervention should the nurse add to the care plan?
- A. Have the child use a bedside commode for elimination.
- B. Administer oxygen after the child uses the bathroom.
- C. Instruct the child to call for assistance when ambulating to the bathroom.
- D. Provide a walker for the child to use when ambulating to the bathroom.
Correct Answer: A
Rationale: Shortness of breath during ambulation may indicate carditis, a serious complication of rheumatic fever. Using a bedside commode minimizes physical exertion, reducing cardiac workload and the risk of worsening symptoms.
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The nurse is caring for a preterm infant with respiratory distress syndrome (RDS). Which intervention should the nurse implement to maximize the infant’s respiratory status?
- A. Check blood glucose levels every 4 hours.
- B. Cool and humidify all inspired gases.
- C. Weigh the infant every other day.
- D. Place the infant in a prone position.
Correct Answer: D
Rationale: The prone position improves oxygenation in collapsed alveoli for RDS infants with cardiorespiratory monitoring. Glucose checks cold gases and infrequent weighing don’t aid respiration.
After the delivery of fetus,placenta should be removed by:
- A. Fundal pressure.
- B. D & C.
- C. Brandt-Andrews method.
- D. Manual removal.
- E. C-section.
Correct Answer: C
Rationale: The Brandt-Andrews method using controlled cord traction is the standard technique for delivering the placenta in the third stage of labor. Other methods are used only in complications.
The nurse is measuring both the chest and head circumference during the full-term newborn’s initial assessment. The newborn’s father observes this and asks the nurse why both measurements are necessary. Which explanation is most accurate?
- A. “Comparing the measurements helps determine if there are head or chest size abnormalities.”
- B. “Measuring the head circumference provides information about future intellectual ability.”
- C. “Measuring the newborn’s chest provides needed information when assessing cardiac health.”
- D. “Comparing the head and chest measurements helps to determine future adult body size.”
Correct Answer: A
Rationale: The circumference of the normal newborn’s head is approximately 2 centimeters greater than the chest at birth. Extreme differences may indicate abnormalities like microcephalus or hydrocephalus. Head size doesn’t predict intelligence chest size doesn’t assess cardiac health and measurements don’t predict adult size.
When a 10-year-old child falls from a bicycle and loses a permanent incisor tooth, which advice can the nurse provide to the parents before they take the child to see a dentist?
- A. Submerge the tooth in water in a cup.
- B. Place the tooth under the child's tongue.
- C. Wrap the tooth in a clean cloth.
- D. Clean the tooth with alcohol.
Correct Answer: C
Rationale: Wrapping the tooth in a clean cloth preserves it for potential reimplantation by keeping it clean and protected without compromising its viability.
The nurse is assessing the full-term Caucasian infant who is 40 hours old. Which technique should the nurse use to evaluate the infant for jaundice?
- A. Remove the infant’s diaper and look at the color of the genitalia.
- B. Apply pressure on the forehead for 3 seconds,release and evaluate the skin color.
- C. Assess the color of the palms and compare that skin color to the color of the soles.
- D. Open the infant’s mouth to assess the color of the infant’s tongue and palate.
Correct Answer: B
Rationale: To differentiate jaundice from normal skin color apply pressure over a bony area like the forehead. A yellow blanched area indicates jaundice. Genitalia palms soles or oral mucosa are less reliable due to slower progression or darker pigmentation.