Nokea
In planning the discharge for a newborn diagnosed with torticollis (wry neck), the nurse should:
- A. Teach the parent the side effects of botulinum toxin (BOTOX).
- B. Coordinate outpatient physical therapy.
- C. Verify the date for corrective surgery.
- D. Demonstrate the use of positioning wedges for sleep.
Correct Answer: B
Rationale: Physical therapy is the most important part of the child's plan of care. Most cases of torticollis respond to gentle stretching exercises, which can be taught to parents and continued at home.
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The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which of the responses by the nurse would be most appropriate?
- A. You really shouldn't leave right now. Your child is very sick.
- B. I understand, but feel free to visit or call anytime to see how your child is doing.
- C. It really isn't necessary to stay with your child. We'll take very good care of him.
- D. Can you find someone to stay with your children? Your child needs you here.
Correct Answer: B
Rationale: This response acknowledges the mother's constraints while encouraging involvement.
After talking with the parents of a child with Down syndrome, the nurse should help the parents establish which goal?
- A. Encouraging self-care skills in the child.
- B. Teaching the child something new each day.
- C. Encouraging more lenient behavior limits for the child.
- D. Achieving age-appropriate social skills.
Correct Answer: A
Rationale: Promoting self-care skills enhances independence and aligns with developmental goals for children with Down syndrome.
After a child undergoes a craniotomy for an infratentorial brain tumor, the nurse should place the child in which of the following positions to prevent undue strain on the sutures?
- A. Prone.
- B. Semi-Fowler's.
- C. Side-lying.
- D. Trendelenburg.
Correct Answer: C
Rationale: Side-lying position minimizes pressure on infratentorial sutures while maintaining airway and reducing intracranial pressure.
The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. When contacting the physician about these symptoms the nurse should request:
- A. A referral to a lactation consultant.
- B. That the physician further assess the client.
- C. An order for an x-ray with orogastric catheter placement.
- D. A serum blood glucose level per laboratory.
Correct Answer: C
Rationale: These symptoms suggest tracheoesophageal fistula, and an x-ray with orogastric catheter placement can confirm the diagnosis by visualizing the anatomy.
The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first:
- A. Administer oxygen.
- B. Institute rewarming.
- C. Prepare for intubation.
- D. Start an intravenous infusion.
Correct Answer: A
Rationale: Administering oxygen addresses hypoxia, the primary concern in near-drowning, to stabilize the child's condition.