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The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. How should the nurse interpret this finding?
- A. Normal finding
- B. Finding requiring a referral
- C. Abnormal finding
- D. Normal finding, but requires rechecking in 1 month
Correct Answer: A
Rationale: The closure of the anterior fontanel in a 14-month-old infant is a normal finding. The anterior fontanel typically closes by around 18 months of age. The closure of the fontanel is a sign of normal growth and development as the bones of the skull fuse together. It is not a cause for concern at this age, and the nurse should document this as a normal finding.
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Why should the nurse wake up a client who is to undergo an EEG at midnight?
- A. Because excess sleep may make the client lazy and nervous for the EEG
- B. Because optimum sleep helps regulate the breathing patterns during the EEG
- C. Because it helps the client to fall asleep naturally during the EEG
- D. Because it reduces the chances of getting a headache when electrodes are fixed to the scalp of the client
Correct Answer: B
Rationale: The nurse should wake up a client who is to undergo an EEG at midnight to ensure that the client receives optimum sleep before the procedure. Optimum sleep helps regulate the client's breathing patterns during the EEG, resulting in more accurate readings. Adequate rest is essential for brain activity monitoring to be as normal as possible. Waking the client at midnight allows for enough time for the client to fall back asleep before the EEG is conducted, ensuring the best possible conditions for the procedure.
A nurse is preparing to feed a 12-month-old infant with failure to thrive. Which intervention should the nurse implement?
- A. Provide stimulation during feeding.
- B. Avoid being persistent during feeding time.
- C. Limit feeding time to 10 minutes.
- D. Maintain a face-to-face posture with the infant during feeding.
Correct Answer: A
Rationale: Providing stimulation during feeding is the most appropriate intervention for a 12-month-old infant with failure to thrive. Infants with failure to thrive may have decreased interest in feeding or difficulty with obtaining adequate nutrition. By providing stimulation during feeding, such as making eye contact, talking gently, and playing soft music, the nurse can help increase the infant's interest and engagement in feeding. This can lead to improved feeding outcomes and help the infant receive the necessary nutrition for growth and development.
Which of the following would the nurse identify as an abnormal finding?
- A. Red blood cells (RBCs): 4.9million/ul
- B. Hematocrit: 45%
- C. Platelets: 115,000/ul
- D. None of the above
Correct Answer: C
Rationale: The normal range for platelets in adults is typically between 150,000 to 400,000 platelets per microliter of blood. A platelet count of 115,000/ul would be considered low, a condition known as thrombocytopenia. Thrombocytopenia can result in difficulty with blood clotting and may lead to increased risk of bleeding. Therefore, a platelet count of 115,000/ul would be identified as an abnormal finding by the nurse.
When teaching umbilical cord care to a new mother, the nurse would include which information?
- A. Apply peroxide to the cord with each diaper change
- B. Cover the cord with petroleum jelly after bathing
- C. Keep the cord dry and open to air
- D. Wash the cord with soap and water each day during a tub bath
Correct Answer: C
Rationale: Keeping the cord dry and open to air is the recommended practice for umbilical cord care. This helps the cord to dry out and fall off naturally. Applying substances like peroxide or petroleum jelly can create a moist environment, which can increase the risk of infection. Washing the cord with soap and water daily can also prolong the time it takes for the cord to fall off. Thus, the best approach is to simply keep the cord clean and dry, allowing it to heal and detach on its own.
Nutritional considerations as part of the nursing care plan would include all of the following except that:
- A. The diet should be semisolid to facilitate the passage of food f. Calcium should be avoided g. The patient should be sitting in an upright position during feeding h. Thick fluids should be encouraged to provide additional calories NEUROLOGIC Situation - Richard Gabatan, a 32-year-old car salesman, suffered a spinal cord injury in a motor vehicle accident resulting to paraplegia.
Correct Answer: B
Rationale: It is important to consider calcium supplementation for patients with spinal cord injuries, especially those with paraplegia, as they are at an increased risk of developing osteoporosis due to decreased weight-bearing activities. Calcium is necessary for bone health and should not be avoided in the diet of patients with spinal cord injuries. Therefore, the statement "Calcium should be avoided" is incorrect in this context as it goes against the nutritional considerations that should be included in the nursing care plan for a patient like Richard Gabatan.