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In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.
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A nurse on a pediatric unit is assigned to care for a child with Reye syndrome. Which of the following is the most serious clinical manifestation for which the nurse should monitor?
- A. Anaphylaxis
- B. Cerebral edema
- C. Impaired coagulation
- D. Hypervolemia
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. In Reye syndrome, cerebral edema is the most serious manifestation due to increased intracranial pressure, potentially leading to brain damage or death. Anaphylaxis (A) is not typically associated with Reye syndrome. Impaired coagulation (C) can occur but is not as immediately life-threatening as cerebral edema. Hypervolemia (D) is a possible complication but not as critical as cerebral edema in Reye syndrome.
Which fetal structure is responsible for carrying oxygenated blood from the placenta to the fetus?
- A. Ductus arteriosus
- B. Umbilical artery
- C. Portal vein
- D. Umbilical vein
Correct Answer: D
Rationale: The correct answer is D: Umbilical vein. The umbilical vein carries oxygenated blood from the placenta to the fetus. This is because the placenta acts as the organ of gas exchange during fetal development. Oxygenated blood from the mother is transferred to the fetus through the umbilical vein. The other choices are incorrect because: A) Ductus arteriosus is a fetal blood vessel that connects the pulmonary artery to the aorta, bypassing the lungs. B) Umbilical artery carries deoxygenated blood from the fetus to the placenta. C) Portal vein carries nutrient-rich blood from the intestines to the liver, not from the placenta to the fetus.
A nurse is preparing to take a rectal temperature on a 7-month-old infant. Which of the following should the nurse keep in mind when preparing to take the temperature?
- A. A well-lubricated thermometer tip should be inserted a maximum of 2.5 in into the rectum.
- B. A rectal temperature of 99.6° F is equal to an oral temperature of 97.7° F.
- C. Infants should have temperatures taken rectally for accuracy and thermoregulation.
- D. Mercury thermometers are the thermometers of choice to obtain the rectal temperature, holding it in place for 4 min.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The correct answer is B because rectal temperatures are typically 1.5-2°F higher than oral temperatures due to the body's core temperature being higher internally. This conversion is essential in accurately interpreting the infant's rectal temperature.
Summary of other choices:
A: Incorrect. The maximum insertion depth for a rectal thermometer in infants is 1 inch, not 2.5 inches.
C: Incorrect. Rectal temperatures are not the only accurate method for infants; axillary or temporal artery thermometers are also reliable.
D: Incorrect. Mercury thermometers are no longer recommended due to the risk of mercury exposure, and the time required to obtain a rectal temperature is typically shorter.
A nurse is reviewing discharge instructions with the parent of an infant who has acute laryngotracheobronchitis (croup).
- A. "I will give my child the corticosteroids prescribed by the doctor."'
- B. "I will clear the child's nasal passages with a bulb syringe to aid in breathing."'
- C. "I will place a dehumidifier in my child's room."'
- D. "I will encourage my child to take plenty of fluids over the next several days."'
Correct Answer: C
Rationale: The correct answer is C: "I will place a dehumidifier in my child's room."
Rationale:
1. Acute laryngotracheobronchitis (croup) is a condition that causes swelling in the upper airway, leading to breathing difficulties.
2. Placing a dehumidifier in the child's room can help maintain optimal humidity levels, which can soothe the inflamed airways and ease breathing.
3. Moist air from the dehumidifier can help reduce coughing and throat irritation, providing comfort to the child.
4. This intervention is specific to managing the symptoms of croup and can support the child's recovery.
Summary:
- Choice A: Corticosteroids are prescribed by the doctor for croup, but it is not the parent's responsibility to administer them.
- Choice B: Clearing nasal passages with a bulb syringe is not directly related to managing croup symptoms.
- Choice D: Encouraging fluids
A client who is 37 weeks gestation comes to the office for a routine visit. This is the client's first baby and she asks the nurse how she will know when labor begins. Which signs indicate that true labor has begun?
- A. Contractions that are irregular and decrease in intensity when walking
- B. Abdominal pain that starts at the fundus and progresses to the lower back
- C. Increased pressure on the bladder and urinary frequency
- D. Expulsion of pink-tinged mucous and contractions that start in the lower back
Correct Answer: D
Rationale: The correct answer is D because the expulsion of pink-tinged mucous (bloody show) and contractions starting in the lower back are indicative of true labor. This is due to the release of the mucus plug and the initiation of true uterine contractions. Contractions that start in the lower back and progress to the front are characteristic of true labor.
Choice A is incorrect because contractions that are irregular and decrease in intensity with walking are characteristic of false labor (Braxton Hicks contractions).
Choice B is incorrect as abdominal pain starting at the fundus and progressing to the lower back is not a specific sign of true labor.
Choice C is incorrect as increased pressure on the bladder and urinary frequency are common throughout pregnancy and not specific to the onset of true labor.
In summary, the correct answer D provides specific and characteristic signs of true labor, while the other choices do not accurately reflect the onset of true labor.