Nokea
The nurse is examining an infant for hip placement and has abducted her flexed legs. The nurse should next:
- A. Rotate the hips.
- B. Extend the legs.
- C. Listen for a "click."
- D. Palpate the hips for a mass.
Correct Answer: C
Rationale: In this scenario, the nurse is performing Ortolani's maneuver, which is used to assess for developmental dysplasia of the hip (DDH) in infants. After abducting the infant's flexed legs, the nurse should then listen for a "click" that may indicate hip instability. A positive click suggests subluxation of the femoral head and may indicate the presence of DDH. It is important for the nurse to recognize this finding promptly and report it to the healthcare provider for further evaluation and management. Rotation of the hips, extending the legs, and palpating for a mass are not the appropriate next steps in this specific assessment for DDH.
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The nurse is teaching nursing students about shock that occurs in children. What is one of the most frequent causes of hypovolemic shock in children?
- A. Sepsis
- B. Blood loss
- C. Anaphylaxis
- D. Congenital heart disease
Correct Answer: B
Rationale: One of the most frequent causes of hypovolemic shock in children is blood loss. Children are at risk for blood loss due to trauma, surgical procedures, gastrointestinal bleeding, or other conditions that result in significant blood volume reduction. Blood loss leads to a decrease in circulating blood volume, which in turn reduces tissue perfusion and oxygen delivery to vital organs. This results in hypovolemic shock, where the heart is unable to pump sufficient blood to meet the body's needs, leading to organ dysfunction and potentially life-threatening complications. Therefore, recognizing and addressing blood loss promptly is essential in managing hypovolemic shock in children.
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?
- A. It usually resolves in 3-6 weeks
- B. It doesn't cross the cranial suture line
- C. It's a collection of blood between the skull and the periosteum
- D. It involves swelling of tissue over the presenting part of the presenting head
Correct Answer: D
Rationale: Caput succedaneum is a condition characterized by the swelling of tissue over the presenting part of the infant's head during delivery. It is commonly a result of prolonged labor or vacuum extraction. Unlike cephalohematoma, caput succedaneum does cross the cranial suture lines. This condition typically resolves within a few days to a week after birth without intervention. It is important to monitor the infant for any complications or signs of infection during the resolution process.
The major manifestation of nephrotic syndrome is:
- A. hematuria.
- B. hyperalbuminemia.
- C. edema.
- D. anemia.
Correct Answer: C
Rationale: The major manifestation of nephrotic syndrome is edema. Nephrotic syndrome is a kidney disorder characterized by increased permeability of the glomerular filtration barrier, leading to excessive protein loss in the urine. This results in low levels of protein in the blood, particularly albumin, leading to a decrease in oncotic pressure. The decreased oncotic pressure causes fluid to accumulate in the interstitial spaces, leading to edema formation. Patients with nephrotic syndrome typically present with periorbital edema, pedal edema, and ascites due to the fluid redistribution in the body. Hematuria, hyperalbuminemia, and anemia are not typically the primary manifestations of nephrotic syndrome.
A 23 y.o. woman is seen at an outpatient clinic for a routine Pap smear. When questioned, she states she is deciding whether to engage in sexual activity with a man she is just getting to know. She asks how she can tell if he has an STD. Which response by the nurse is best?
- A. "If the man appears clean and has been conscientious about using condoms, he is likely infection free."
- B. "Look carefully for signs of lesions before engaging in sexual activity."
- C. "Be sure to use either a male or female condom to protect against possible transmission of infection."
- D. "An examination by a physician with diagnostic testing is the only way to know if he is infection free."
Correct Answer: D
Rationale: The best response by the nurse is to recommend an examination by a physician with diagnostic testing as the only way to know if the potential partner is infection free. Simply relying on the appearance of cleanliness or condom use may not be sufficient to determine the presence of sexually transmitted infections (STIs) such as HPV, chlamydia, or herpes, which may not have visible symptoms. Encouraging regular testing and open communication about sexual health with partners is crucial in preventing the spread of STIs.
The age by which the child can make a tower of 9 cubes and imitates circular stroke is
- A. 24 months
- B. 30 months
- C. 36 months
- D. 42 months
Correct Answer: C
Rationale: This milestone is typically achieved around 36 months.