Nokea
If the parents report all the following history findings to the nurse, which one is most closely correlated with an increased risk of rheumatic fever?
- A. The child was exposed to measles within the past 4 weeks.
- B. The child had a severe sore throat within the past 2 weeks.
- C. The child is lethargic and no longer interested in schoolwork.
- D. The child received a bump on the head while playing.
Correct Answer: B
Rationale: Rheumatic fever is strongly associated with a recent streptococcal infection, such as a sore throat caused by group A Streptococcus. A severe sore throat within the past 2 weeks is a key risk factor, as it may indicate an untreated or inadequately treated streptococcal infection.
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During early postburn care of the child, it is essential for the nurse to closely monitor which of the following?
- A. Unburned skin
- B. Bowel elimination
- C. I.V. fluid therapy
- D. Pupillary response to light
Correct Answer: C
Rationale: I.V. fluid therapy is critical in the early postburn phase to prevent hypovolemic shock and maintain organ perfusion. Close monitoring ensures adequate resuscitation and prevents complications like over- or under-hydration.
The nurse is completing the 1-minute Apgar assessment on the full-term newborn. The newborn’s HR is 80 bpm. What should the nurse do next?
- A. Assign a 2 for the Apgar score that pertains to the heart rate.
- B. Suction the excess secretions from the newborn’s oral cavity.
- C. Wrap in warm blankets and place on the mother’s abdomen.
- D. Begin immediate positive pressure ventilation on the newborn.
Correct Answer: D
Rationale: A newborn HR of less than 100 bpm scores as a 1 on the HR criterion and indicates a need to begin positive pressure ventilation by bag mask or Neopuff® ventilation. A score of 2 requires HR above 100 bpm. Suctioning is not indicated and wrapping is done after assessment.
Because of the length of time the client must remain in skeletal traction, the nurse correctly assesses for evidence of skin breakdown in which area?
- A. Over the child's calves
- B. Over the child's scapulae
- C. On the child's knees
- D. On the child's buttocks
Correct Answer: D
Rationale: Prolonged immobility in traction increases pressure on the buttocks, a common site for skin breakdown due to constant contact with the bed.
A 30 years old G3P2 at 28 weeks of gestation presents with severe pain in the right flank radiating to her groin. She also complaints of rigors and chills. Urine analysis reveals numerous pus cells. The most likely diagnosis is:
- A. Appendicitis.
- B. Pyelonephritis.
- C. Round ligament torsion.
- D. Meckel's diverticulum.
- E. Torsion of ovarian cyst.
Correct Answer: B
Rationale: Pyelonephritis a urinary tract infection affecting the kidneys presents with flank pain fever,chills,and pus cells in urine,as described. Appendicitis typically involves right lower quadrant pain and other options lack urinary findings or are less likely in pregnancy.
The nurse has just assisted with the birth of a full-term infant. The nurse should take which measures immediately to promote parent-infant attachment? Select all that apply.
- A. Have the mother nap before interacting with her newborn.
- B. Dim the lights in the birthing room.
- C. Place the newly delivered infant on the mother’s abdomen.
- D. Delay instilling the ophthalmic antibiotic for an hour.
- E. Play loud music to keep the infant stimulated.
- F. Ask the parents to delay phone calls for an hour after birth.
Correct Answer: B,C,D,F
Rationale: Dimming lights encourages eye contact skin-to-skin contact improves interaction delaying antibiotic ointment prevents blurred vision and delaying phone calls maximizes bonding time. Napping misses the alert period and loud music is overstimulating.