Nokea
The nurse is assessing the infant shown in the figure. On observing the infant from this angle, the nurse should document that this infant has which of the following?
- A. Ortolani's 'click.'
- B. Limited abduction.
- C. Galeazzi's sign.
- D. Asymmetric gluteal folds.
Correct Answer: D
Rationale: Asymmetric gluteal folds are a clinical sign of developmental dysplasia of the hip, indicating possible hip dislocation or asymmetry.
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A child with a lead level of 20 mcg/dL is prescribed oral chelation therapy. The nurse should monitor for which side effect?
- A. Hypertension.
- B. Renal toxicity.
- C. Hypoglycemia.
- D. Seizures.
Correct Answer: B
Rationale: Oral chelators like succimer can cause renal toxicity, requiring monitoring of kidney function. Hypertension, hypoglycemia, and seizures are not common side effects.
The nurse is planning care with the parents of a child who requires continuous peritoneal dialysis. Which finding should be discussed with the physician?
- A. The family lives a long distance from the medical facility.
- B. The child attends a large public school.
- C. The child reports having a previous surgery for a ruptured appendix.
- D. The family feels the child cannot self-regulate to wake at night and change bags.
Correct Answer: C
Rationale: Previous surgery might impact current care.
The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arch the back (see figure). The nurse should:
- A. Notify the physician
- B. Stroke the back to release the arching
- C. Pad the side rails of the crib
- D. Place the child prone
Correct Answer: A
Rationale: The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify the physician immediately and have resuscitation equipment ready. Stroking the back will not relieve the herniation or release the arching. Although the infant may also have a seizure, and padded side rails will prevent injury, the fi rst action is to notify the physician. Placing the child in a prone position will not relieve the herniation or release the arching.
A 10-year-old child who is 5'4' (138 cm) tall with a history of asthma uses an inhaled bronchodilator only when needed. He takes no other medications routinely. His best peak expiratory flow rate is 270 L/minute. The child's current peak flow reading is 180 L/minute. The nurse interprets this reading as indicating which of the following?
- A. The child's asthma is under good control, so the routine treatment plan should continue.
- B. The child needs to start a short-acting inhaled beta-agonist medication.
- C. This is a medical emergency requiring a trip to the emergency department for treatment.
- D. The child needs to begin treatment with inhaled cromolyn sodium (Intal) for asthma control.
Correct Answer: B
Rationale: A peak flow reading of 180 L/minute is 66.7% of the child's best (270 L/minute), placing it in the yellow zone (50-80% of personal best), indicating an asthma exacerbation. A short-acting inhaled beta-agonist is needed to relieve symptoms.
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.