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The nurse is monitoring a child with hydrocephalus who received a ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?
- A. The child has grown in height since the previous shunt placement
- B. The child reports no evidence of continuous headaches
- C. An intracranial pressure (ICP) monitoring probe is in place
- D. The child is afebrile with normal vital signs postoperatively.
Correct Answer: B
Rationale: Absence of continuous headaches indicates the shunt is relieving brain pressure effectively.
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The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?
- A. Position prone after feeding.
- B. Breastfeed frequently.
- C. Avoid smoke exposure.
- D. Inspect the infant's ears daily.
Correct Answer: C
Rationale: Avoiding smoke exposure reduces eustachian tube irritation, lowering otitis media risk.
The nurse is teaching a school-age child with left femoral osteomyelitis and the child's parent before discharge. What instruction should the nurse give related to the initial phase of treatment?
- A. Ensure no weight bearing on the affected extremity
- B. Administer topical antibiotic therapy daily
- C. Schedule ice pack applications to the infected area
- D. Provide passive range of motion exercises
Correct Answer: A
Rationale: No weight bearing prevents further bone damage during the initial treatment phase of osteomyelitis, supporting infection control.
A 5-week-old infant who has been experiencing projectile vomiting after feedings. What additional symptom should the nurse anticipate?
- A. Stool containing mucus and blood.
- B. An olive-sized mass in the epigastric region.
- C. Frequent burping accompanied by poor feeding.
- D. Rebound tenderness in the left lower abdominal quadrant.
Correct Answer: B
Rationale: An olive-sized mass suggests pyloric stenosis, a common cause of projectile vomiting.
A 7-year-old child has been admitted to the hospital with a diagnosis of acute rheumatic fever. When taking a health history from the child's mother, which recent illness is of most significance?
- A. Chickenpox.
- B. Mumps.
- C. Sore throat.
- D. Influenza.
Correct Answer: C
Rationale: A recent untreated strep throat can lead to acute rheumatic fever.
The nurse observes a mother administering ferrous sulfate (iron drops) to her 11-month-old child, followed by 2 ounces (60 mL) of orange juice. What should be the nurse's subsequent action?
- A. Advise the mother to follow the iron drops with infant formula instead of orange juice.
- B. Commend the mother on her method of administering the medication.
- C. Propose mixing the iron drops in the orange juice before feeding the infant.
- D. Direct the mother to refrain from feeding the infant for 30 minutes after giving the iron drops.
Correct Answer: B
Rationale: Orange juice's vitamin C enhances iron absorption, making the method appropriate.