Nokea
On the third day of hospitalization, the nurse observes that a 2-year-old toddler who had been screaming and crying inconsolably begins to regress and is now lying quietly in the crib with a blanket. What stage of separation anxiety has developed?
- A. Denial
- B. Despair
- C. Mistrust
- D. Rejection
Correct Answer: B
Rationale: The correct answer is B: Despair. In separation anxiety, the stage of despair is characterized by regression and withdrawal after an initial period of protest. The child may become quiet and appear to accept the separation, but this is actually a sign of deeper distress. Choice A, Denial, is incorrect as it refers to refusing to believe or accept the reality of the separation. Choice C, Mistrust, is incorrect as it pertains to a lack of trust in others, not a stage of separation anxiety. Choice D, Rejection, is incorrect as it involves pushing others away and not related to the described behavior of the toddler in the scenario.
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At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. Which of the following statements regarding crowning is true?
- A. Crowning represents the end of the second stage of labor.
- B. Crowning always occurs immediately after the amniotic sac has ruptured.
- C. It is safe to transport the patient during crowning if the hospital is close.
- D. Gentle pressure should be applied to the baby's head during crowning.
Correct Answer: D
Rationale: During crowning, it is essential to apply gentle pressure to the baby's head to prevent rapid delivery, which can lead to potential injuries to both the mother and the baby. Choice A is incorrect because crowning signifies the beginning, not the end, of the second stage of labor. Choice B is incorrect as crowning can occur before or after the amniotic sac ruptures. Choice C is incorrect as transporting the patient during crowning, even if the hospital is close, can be unsafe due to the risk of rapid delivery and complications.
An 8-year-old girl was diagnosed with a closed fracture of the radius at approximately 2 p.m. The fracture was reduced in the emergency department, and her arm placed in a cast. At 11 p.m., her mother brings her back to the emergency department due to unrelenting pain that has not been relieved by the prescribed narcotics. Which action would be the priority?
- A. Notifying the doctor immediately
- B. Applying ice
- C. Elevating the arm
- D. Giving additional pain medication as ordered
Correct Answer: A
Rationale: The correct action would be to notify the doctor immediately. Unrelenting pain despite medication can indicate compartment syndrome, which is a medical emergency requiring immediate attention. Applying ice or elevating the arm may not address the potential serious underlying issue of compartment syndrome. Giving additional pain medication without further assessment could delay necessary intervention and potentially worsen the condition.
A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should alert the nurse to perform a further assessment?
- A. Flat occiput
- B. Small, low-set ears
- C. Circumoral cyanosis
- D. Protruding furrowed tongue
Correct Answer: C
Rationale: Circumoral cyanosis should alert the nurse to perform further assessment in a 2-month-old infant with Down syndrome. This finding may indicate cardiac or respiratory issues, such as inadequate oxygenation. Small, low-set ears and a protruding furrowed tongue are common physical characteristics associated with Down syndrome and may not necessarily warrant immediate further assessment. A flat occiput is a normal variation in infant anatomy and is not typically a cause for immediate concern in this context.
While performing a visual inspection of a 30-year-old woman in active labor, you can see the umbilical cord at the vaginal opening. After providing high concentration oxygen, what should you do next?
- A. massage the uterus to facilitate delivery of the fetus
- B. relieve pressure from the cord with your gloved fingers
- C. place the mother on her left side and provide rapid transport
- D. elevate the mother's lower extremities and provide immediate transport
Correct Answer: B
Rationale: In the scenario described, the priority is to relieve pressure from the umbilical cord protruding from the vaginal opening by gently pushing it back inside using your gloved fingers. This action helps prevent cord compression, maintains blood flow to the fetus, and ensures fetal oxygenation. Massaging the uterus (Choice A) is not appropriate in this situation as it can potentially worsen the cord compression. Placing the mother on her left side and providing rapid transport (Choice C) can be considered after relieving the pressure on the cord. Elevating the mother's lower extremities and providing immediate transport (Choice D) is not the correct approach when dealing with a visible umbilical cord; instead, the focus should be on relieving pressure from the cord to prevent fetal compromise.
A parent calls the clinic because their child has ingested a small amount of household bleach. What should the nurse advise?
- A. Administer activated charcoal
- B. Induce vomiting immediately
- C. Call the poison control center
- D. Take the child to the emergency department
Correct Answer: C
Rationale: The correct answer is to advise the parent to call the poison control center. When a child ingests household bleach, it is important to seek guidance from professionals who can provide specific and immediate advice on managing the situation. Administering activated charcoal (Choice A) is not recommended for household bleach ingestion. Inducing vomiting immediately (Choice B) can lead to further complications and is not the recommended first response. Taking the child to the emergency department (Choice D) should be done based on the advice received from the poison control center.