Nokea
The nurse completes teaching in preparation to discharge a mother and her 48-hour-old,full-term newborn. The nurse determines there is a need for further instruction about infant car safety when the newborn’s father is overheard making which statement?
- A. “We need to face the infant car seat toward the back of the car.”
- B. “I disarmed one front seat air bag so we can put the car seat in the front seat.”
- C. “Let’s check the car seat to make sure it will position the baby at a 45-degree angle.”
- D. “I know the baby will need to be in the infant car seat until he is over 20 pounds.”
Correct Answer: B
Rationale: The rear seat is safest for infants; air bags should not be disarmed for front-seat placement. Rear-facing 45-degree angle and car seat use until 20 lb are correct.
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The physician orders 500 mg of a medication to be given I.V. over 4 hours. The medication is diluted in 100 mL of fluid. What is the hourly flow rate in milliliters?
Correct Answer: 25 mL/hour
Rationale: Calculation: 100 mL over 4 hours = 100 ÷ 4 = 25 mL/hour. Since no options are provided, the calculated rate is noted for accuracy.
When is the correct time for the nurse to administer the child's morning dose of a combination regular and NPH insulin?
- A. 30 minutes before breakfast is served
- B. 15 minutes before breakfast is served
- C. 30 minutes after breakfast is served
- D. 15 minutes after breakfast is served
Correct Answer: A
Rationale: Regular insulin peaks in 2-4 hours, and NPH peaks in 4-12 hours. Administering the combination 30 minutes before breakfast aligns insulin onset with food intake, controlling postprandial glucose levels effectively.
Of the following methods,the safest,most precise and simplest for placental localization is:
- A. Auscultation.
- B. Ultrasonography.
- C. Radioisotope study.
- D. Abdominal palpation.
- E. Soft tissue radiography.
Correct Answer: B
Rationale: Ultrasonography is the safest most precise and simplest method for placental localization offering real-time imaging without radiation. Other methods are less accurate or involve risks.
When discussing cerebral palsy with the parents of a newly diagnosed child, which information is correct?
- A. Cerebral palsy is a nonprogressive disease caused by damage to the brain.
- B. Brain surgery commonly helps or even cures children with cerebral palsy.
- C. Physical therapy is of little value to a child with cerebral palsy.
- D. Cerebral palsy is the result of injury to the sensory areas of the brain.
Correct Answer: A
Rationale: Cerebral palsy is a nonprogressive neurological disorder caused by brain damage, often before or during birth, affecting motor function but not worsening over time.
Which finding documented by the nurse is most indicative of a client with rheumatic fever?
- A. Slow, irregular heartbeat
- B. Blotchy, diffuse erythema
- C. Decreased antistreptolysin O titer (ASO titer)
- D. Generalized migrating joint tenderness
Correct Answer: D
Rationale: Generalized migrating joint tenderness (polyarthritis) is a hallmark symptom of rheumatic fever, reflecting the inflammatory process affecting multiple joints. An elevated ASO titer (not decreased) would indicate a recent streptococcal infection, and the other options are less specific.