Nokea
The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.)
- A. Warm flushed extremities
- B. Weight loss
- C. Decreased urinary output
- D. Sweating (inappropriate)
Correct Answer: C
Rationale: C. Decreased urinary output: This can be a sign of fluid retention, which is a common symptom of heart failure. Infants with heart failure may have decreased urine output as the body tries to retain fluid to help compensate for the heart's decreased ability to pump effectively.
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A highly careful mother of a 10-month-old baby boy complains of inadequate weight gain due to refusal of spoon feeding. The LEAST helpful advice is to
- A. respect infant independence
- B. offer softer diet
- C. use 2 spoons (1 for the child and 1 for the parent)
- D. use finger foods
Correct Answer: B
Rationale: Offering softer food may not address the underlying issue of refusal.
According to Piaget, the 6-month-old infant should be in which developmental stage?
- A. Use of reflexes
- B. Primary circular reactions
- C. Secondary circular reactions
- D. Coordination of secondary schemata
Correct Answer: B
Rationale: According to Piaget's theory of cognitive development, the 6-month-old infant would typically be in the stage known as primary circular reactions. This stage occurs from around 1 to 4 months of age up to about 1 year old. During this stage, infants begin to repeat actions that bring them pleasure or interesting results, such as sucking their thumb or repeating simple movements like kicking. These repetitive actions are circular in nature because they involve the infant's own body, and they serve as the building blocks for more complex interactions and understanding of the world. This stage is characterized by the infant's increasing ability to coordinate sensory information with motor actions, laying the foundation for further cognitive development.
The parent of a 2-week-old infant, exclusively breastfed, asks the nurse if fluoride supplements are needed. What is the nurse's best response?
- A. "She needs to begin taking them now."
- B. "They are not needed if you drink fluoridated water."
- C. "She may need to begin taking them at age 4 months."
- D. "She can have infant cereal mixed with fluoridated water instead of supplements."
Correct Answer: B
Rationale: The nurse's best response to the parent of a 2-week-old infant, exclusively breastfed, regarding the need for fluoride supplements is that they are not needed if the infant is already drinking fluoridated water. Fluoride supplements are typically recommended for infants who are not receiving enough fluoride through their water source. Breast milk itself does not contain a significant amount of fluoride, but if the family's water supply is fluoridated, the infant will likely receive an adequate amount of fluoride without the need for supplements. It is important for the parent to verify the fluoride content of their water supply with their local water utility to ensure the infant is receiving the appropriate amount of fluoride for dental health.
An adolescent girl calls the nurse at the clinic because she had unprotected sex the night before and does not want to be pregnant. What should the nurse explain to the girl?
- A. It is too late to prevent an unwanted pregnancy
- B. An abortion may be the best option if she is pregnant
- C. Norplant can be administered to prevent pregnancy for up to 5 years
- D. Postcoital contraception is available to prevent implantation
Correct Answer: D
Rationale: In this scenario, the most appropriate option for the nurse to explain to the adolescent girl is postcoital contraception, also known as emergency contraception or the morning-after pill. Postcoital contraception is a method used to prevent pregnancy after unprotected sex or contraceptive failure. It works by preventing or delaying ovulation, inhibiting fertilization, or preventing implantation of a fertilized egg in the uterus.
The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might be most helpful?
- A. Suggest that the child keep a diary.
- B. Suggest that the parent read fairy tales to the child.
- C. Ask the parent if the child is always uncommunicative.
- D. Ask the child to draw a picture.
Correct Answer: D
Rationale: Asking the child to draw a picture can be the most helpful technique in this situation because it allows the child to express themselves visually, especially when verbal communication may be challenging. Drawing can serve as a form of communication that the child may find more comfortable and engaging. It provides the child with a non-verbal way to express their thoughts, feelings, and experiences, which can help the nurse better understand the child's perspective and potentially build a connection with them. Additionally, examining the child's drawings can provide valuable insights into their emotional state and concerns, facilitating more effective care and support.