Nokea
The nurse is caring for a child with Guillain-Barré syndrome. Which symptom is most critical to monitor?
- A. Paresthesia in the legs.
- B. Difficulty walking.
- C. Ascending paralysis affecting respiratory muscles.
- D. Hoarseness during speech.
Correct Answer: C
Rationale: Ascending paralysis impacting respiratory muscles poses a life-threatening risk, necessitating close monitoring.
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A newborn was found to have the following anomalies: hydrocephalus, cicatricial scarring over the 6th-7th left intercostals, malformed feet (fusion and maldevelopment of both feet). Which congenital infection shows these findings at birth?
- A. HIV
- B. CMV
- C. Parvovirus B19
- D. Varicella-Zoster virus
Correct Answer: D
Rationale: Varicella-Zoster causes congenital varicella syndrome with limb defects, scarring, and CNS anomalies.
When assessing a newborn for developmental dysplasia of the hip, the nurse would expect to assess which of the following?
- A. Symmetrical gluteal folds
- B. Trendelenburg sign
- C. Ortolani's sign
- D. Characteristic limp
Correct Answer: C
Rationale: Ortolani's sign is the abnormal clicking sound when the hips are abducted, indicating developmental dysplasia in newborns.
Parents of a child with leukemia are exploring alternative treatments. What is the nurse's best response?
- A. Alternative therapies are safer than chemotherapy.
- B. Discuss any complementary therapies with your oncologist first.
- C. Discontinue chemotherapy before starting alternative treatments.
- D. Avoid any treatments that involve herbs or supplements.
Correct Answer: B
Rationale: Complementary therapies should always be discussed with the oncologist to avoid harmful interactions.
When teaching a group of new parents about newborn care and development, which immunoglobulin would the nurse explain as being primarily responsible for the passive immunity exhibited by newborns?
- A. IgA
- B. IgG
- C. IgM
- D. IgE
Correct Answer: B
Rationale: IgG is acquired transplacentally, providing the newborn with passive immunity to antigens to which the mother had developed antibodies. IgA, IgD, IgE, and IgM do not cross the placenta and require an antigenic challenge for production.
A 10-year-old with hemophilia is admitted for knee swelling after a fall. What is the nurse's priority action?
- A. Encourage ambulation to prevent stiffness.
- B. Apply warm compresses to the knee.
- C. Administer the prescribed clotting factor.
- D. Elevate the leg to reduce swelling.
Correct Answer: C
Rationale: Administering clotting factor promptly controls bleeding and reduces joint damage in hemophilia patients.