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A nurse is reinforcing teaching with the parents of an infant diagnosed with recurrent otitis media. Which of the following is appropriate teaching to include?
- A. Give the child an over-the-counter antihistamine when the symptoms begin.
- B. Hold the child in an upright position while feeding.
- C. Talk with the primary health care provider about performing a tonsillectomy.
- D. Apply a warm compress over the affected ear to provide comfort.
Correct Answer: B
Rationale: The correct answer is B: Hold the child in an upright position while feeding. This is important because feeding the infant in an upright position can help prevent reflux of milk into the Eustachian tube, reducing the risk of otitis media. This position helps to promote proper drainage and ventilation of the middle ear, decreasing the likelihood of infection.
Incorrect answers:
A: Giving the child an over-the-counter antihistamine is not appropriate for otitis media, as it is typically caused by bacterial infection, not allergies.
C: Tonsillectomy is not a first-line treatment for otitis media. It is usually considered if the child has recurrent tonsillitis, not otitis media.
D: Applying a warm compress over the affected ear may provide comfort but does not address the underlying cause or prevention of otitis media.
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In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.
A nurse is checking children at an orthopedic outpatient setting. Which of the following should the nurse expect to see as manifestations of scoliosis?
- A. Pain and an exaggerated lumbar curvature'
- B. Uneven shoulder heights and poorly fitting slacks'
- C. Tenderness and swelling of the spine'
- D. Limited range of motion of the back and a limp'
Correct Answer: B
Rationale: The correct answer is B. Uneven shoulder heights and poorly fitting slacks are common manifestations of scoliosis because the condition causes an abnormal curvature of the spine, leading to uneven shoulders and hips. Pain and exaggerated lumbar curvature (choice A) are not specific manifestations of scoliosis. Tenderness and swelling of the spine (choice C) could indicate other conditions like infection or inflammation, not necessarily scoliosis. Limited range of motion of the back and a limp (choice D) are more indicative of musculoskeletal injuries or disorders, not scoliosis.
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?
- A. My partner will put the condom on while his penis is erect.
- B. I will remove the condom 30 minutes after intercourse.
- C. My partner should leave an empty space at the tip.
- D. I can use spermicidal gels or creams to increase effectiveness.
Correct Answer: B
Rationale: The correct answer is B because removing the condom 30 minutes after intercourse is incorrect. Condoms should be removed immediately after ejaculation to prevent leakage or spillage of semen. Leaving the condom on for too long increases the risk of pregnancy and STIs. Choice A is correct as putting the condom on while the penis is erect is the proper way to ensure it fits securely. Choice C is also correct as leaving a small space at the tip allows room for semen collection. Choice D is incorrect because spermicidal gels or creams are not recommended with condoms as they can cause irritation and may not increase effectiveness.
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply).
- A. Heart Rate 154/min
- B. Axillary temperature 96.8 F
- C. Respiratory rate 58/min
- D. Length 43 cm (16.9in)
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
1. Heart rate of 154/min is expected in a newborn, indicating normal cardiac function.
2. Axillary temperature of 96.8 F is within the normal range for a newborn.
3. Respiratory rate of 58/min is expected due to the newborn's immature respiratory system.
4. Length of 43 cm (16.9 in) falls within the normal range for a newborn's size.
Incorrect choices are not applicable due to lack of details, but in general, incorrect options would have included values outside the normal range for a newborn's physical assessment.
The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:
- A. Needed brief oral and nasal suctioning.
- B. Required endotracheal intubation and bagging with a hand-held resuscitator.
- C. Was stillborn and required CPR.
- D. Required physical stimulation and supplemental oxygen.
Correct Answer: D
Rationale: The correct answer is D: Required physical stimulation and supplemental oxygen. The Apgar score assesses a newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 5 at one minute indicates the infant needed assistance, such as stimulation to breathe and oxygen support. The score of 7 at five minutes shows improvement but still requires some intervention. Choices A, B, and C are incorrect because they suggest more aggressive interventions that are not indicated based on the Apgar scores provided, as the infant's condition was not critical enough to warrant those actions.