Nokea
The nurse is assessing a neonate with suspected tracheoesophageal fistula. Which of the following findings would be most concerning?
- A. Excessive drooling.
- B. Mild cyanosis during feeding.
- C. Heart rate of 140 bpm.
- D. Temperature of 37°C.
Correct Answer: B
Rationale: Mild cyanosis during feeding indicates potential airway compromise, a critical concern in TEF.
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When developing the discharge teaching plan for the parents of a child who has undergone a cardiac catheterization for ventricular septal defect, which of the following should the nurse expect to include?
- A. Restriction of the child's activities for the next 3 weeks.
- B. Use of sponge baths until the stitches are removed.
- C. Use of prophylactic antibiotics before receiving any dental work.
- D. Maintenance of a pressure dressing until a return visit with the physician.
Correct Answer: C
Rationale: Prophylactic antibiotics are recommended before dental procedures for children with ventricular septal defects to prevent endocarditis. Activity restrictions are typically shorter, stitches are not always used, and pressure dressings are removed sooner.
The nurse is assisting with conscious sedation for a 6-year-old undergoing a bone marrow biopsy. The nurse's most important responsibility during the procedure is to:
- A. Administer the topical anesthetic.
- B. Keep the parents informed.
- C. Monitor the client.
- D. Record the procedure.
Correct Answer: C
Rationale: Monitoring the child during conscious sedation ensures safety, detecting respiratory or cardiovascular changes promptly.
A nasogastric tube is ordered to be inserted for a child with severe head trauma. Diagnostic testing reveals that the child has a basilar skull fracture. What should the nurse do next?
- A. Ask for the order to be changed to oral gastric tube.
- B. Attempt to place the tube into the duodenum.
- C. Test the gastric aspirate for blood.
- D. Use extra lubrication when inserting the nasogastric tube.
Correct Answer: A
Rationale: Basilar skull fractures contraindicate NG tube insertion due to the risk of cranial penetration; an oral gastric tube is safer.
A nurse walks into the room just as a 10-month-old infant places an object in his mouth and starts to choke. After opening the infant's mouth, which of the following should the nurse do next to clear the airway?
- A. Use blind finger sweeps.
- B. Deliver back slaps and chest thrusts.
- C. Apply four subdiaphragmatic abdominal thrusts.
- D. Attempt to visualize the object.
Correct Answer: B
Rationale: For a 10-month-old choking, delivering back slaps and chest thrusts is the recommended method to dislodge a foreign body, as per pediatric guidelines.
When developing the plan of care for an infant with myelomeningocele and the parents who have just been informed of the infant's diagnosis, which action should the nurse include as the priority when the parents visit the infant for the first time?
- A. Emphasizing the infant's normal and positive features.
- B. Encouraging the parents to discuss their fears and concerns.
- C. Reinforcing the doctor's explanation of the defect.
- D. Having the parents feed their infant.
Correct Answer: A
Rationale: Highlighting normal features helps parents bond with their infant and fosters a positive perception, which is critical initially after a diagnosis.