Nokea
The nurse is caring for an infant diagnosed with laryngomalacia (congenital laryngeal stridor). In which position should the nurse place the infant to decrease the incidence of stridor?
- A. Prone
- B. Supine
- C. Supine with the neck flexed
- D. Prone with the neck hyperextended
Correct Answer: D
Rationale: The prone position with the neck hyperextended improves the child's breathing. Based on that information, none of the remaining options are appropriate positions.
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The mother of the child with a diagnosis of hepatitis B calls the health care clinic to report that the jaundice seems to be worsening. Which response should the nurse make to the mother?
- A. It sounds as if the hepatitis may be worsening.'
- B. It is necessary to isolate the child from others in the home.'
- C. The jaundice may appear to get worse before it begins to resolve.'
- D. You need to bring the child to the health care clinic to see the primary health care provider.'
Correct Answer: C
Rationale: The parents should be instructed that jaundice may appear to get worse before it resolves. The parents of a child with hepatitis should also be taught the danger signs that could indicate a worsening of the child's condition, specifically changes in neurological status, bleeding, and fluid retention. Based on this information, the statements in the remaining options are incorrect.
A mother of a child with mumps calls the health care clinic to tell the nurse that the child has been lethargic and vomiting. What instruction should the nurse give to the mother?
- A. To continue to monitor the child
- B. That lethargy and vomiting are normal manifestations of mumps
- C. To bring the child to the clinic to be seen by the primary health care provider
- D. That, as long as there is no fever, there is nothing to be concerned about
Correct Answer: C
Rationale: Mumps generally affects the salivary glands, but it can also affect multiple organs. The most common complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the primary health care provider.
A client begins to experience seizure activity while in bed. The nurse should provide which intervention to prevent aspiration?
- A. Raise the head of the bed.
- B. Loosen restrictive clothing.
- C. Remove the pillow and raise the padded side rails.
- D. Position the client on the side with the head flexed forward.
Correct Answer: D
Rationale: Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates the drainage of secretions, which could help prevent aspiration. The nurse would not raise the head of the client's bed. The nurse would remove restrictive clothing and the pillow and raise the padded side rails, if present, but these actions would not decrease the risk of aspiration; rather, they are general safety measures to use during seizure activity.
The nurse caring for a child who has sustained a head injury notes that the primary health care provider has documented decorticate posturing. During the assessment of the child, the nurse notes the extension of the upper extremities and the internal rotation of the upper arms and wrists. The nurse also notes that the lower extremities are extended, with some internal rotation noted at the knees and feet. On the basis of these findings, what is the initial nursing action?
- A. Document that the original positioning is unchanged.
- B. Attempt to assess the flexibility of the child's lower extremities.
- C. Plan to continue to monitor the child for posturing every 2 hours.
- D. Notify the primary health care provider of the change in posturing.
Correct Answer: D
Rationale: Decorticate (flexion) posturing refers to the flexion of the upper extremities and the extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate (extension) posturing involves the extension of the upper extremities with the internal rotation of the upper arms and wrists. The lower extremities will extend with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Although documentation is appropriate, it is not the initial action in this situation. The other options are not appropriate.
A client in the late, active, first stage of labor has just reported a gush of vaginal fluid. The nurse observes a fetal monitor pattern of variable decelerations during contractions followed by a brief acceleration. After that, there is a return to baseline until the next contraction, when the pattern is repeated. On the basis of these data, what is the nurse's initial intervention?
- A. Take the client's vital signs.
- B. Perform a Leopold's maneuver.
- C. Perform a manual sterile vaginal exam.
- D. Test the vaginal fluid with a Nitrazine strip.
Correct Answer: C
Rationale: Variable deceleration with brief acceleration after a gush of amniotic fluid is a common clinical manifestation of cord compression caused by occult or frank prolapse of the umbilical cord. A manual vaginal exam can detect the presence of the cord in the vagina, which confirms the problem. On the basis of the data in the question, none of the remaining options are initial actions.