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The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child's head appears large in relation to body size. Which action is most important for the nurse to take next?
- A. Measure the infant's head-to-heel length
- B. Observe the infant for sunsetting eyes
- C. Palpate the anterior fontanel for tension and bulging
- D. Plot the measurement on the infant's growth chart
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When assessing a child with HIV, which system should the nurse assess first?
- A. Assess the respiratory system.
- B. Assess the gastrointestinal system.
- C. Assess the cardiovascular system.
- D. Assess the neurological system.
Correct Answer: A
Rationale: When assessing a child with HIV, it is essential to prioritize assessing the respiratory system first. Children with HIV are more susceptible to respiratory infections and complications, such as pneumonia, due to their weakened immune system. Identifying any respiratory issues early on can help in prompt intervention and management, thus improving outcomes for the child.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate?
- A. Drowsiness and bradycardia.
- B. Depressed reflexes and increased respirations.
- C. Tachycardia and a feeling of nervousness.
- D. A flushed, warm feeling and a dry mouth.
Correct Answer: C
Rationale: The primary side effects of terbutaline sulfate are related to its beta-adrenergic effects. Tachycardia and nervousness are common side effects of terbutaline sulfate. Tachycardia is expected due to the drug's beta-agonist properties, while nervousness can result from the stimulation of beta-adrenergic receptors. It is crucial to monitor the client for these side effects to ensure early recognition and appropriate management.
The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside?
- A. Litmus paper.
- B. Fetal scalp electrode.
- C. A sterile glove.
- D. Needle and Thread
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child?
- A. Reduce cerebral edema and lower intracranial pressure
- B. Avert hypotension and septic shock
- C. Prevent cardiac arrhythmias and heart failure
- D. Promote kidney perfusion and normal blood pressure
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When counseling a couple seeking information about conceiving, the LPN/LVN should know that ovulation usually occurs
- A. two weeks before menstruation.
- B. immediately after menstruation.
- C. immediately before menstruation.
- D. three weeks before menstruation.
Correct Answer: A
Rationale: Ovulation typically occurs about 14 days before the start of the next menstrual period. This timing allows for the released egg to travel down the fallopian tube where it may be fertilized by sperm, leading to conception. Understanding the timing of ovulation is crucial for couples trying to conceive to increase their chances of success.