Nokea
The nurse is preparing to administer an injection to a six-month-old when she notices a white dot in the infant's right pupil. The nurse should:
- A. Report the finding to the physician immediately.
- B. Record the finding and give the infant's injection.
- C. Recognize that the finding is a variation of normal.
- D. Check both eyes for the presence of the red reflex.
Correct Answer: A
Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or other serious conditions, requiring immediate reporting to the physician for evaluation.
You may also like to solve these questions
A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:
- A. Gently pull the infant away
- B. Withdraw the breast from the infant's mouth
- C. Compress the areolar tissue until the infant drops the nipple from her mouth
- D. Insert a clean finger into the baby's mouth beside the nipple
Correct Answer: D
Rationale: Inserting a finger into the infant's mouth breaks suction, allowing nipple removal without trauma. Other methods risk nipple injury.
A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client's diagnosis?
- A. Smoking a pack of cigarettes a day for 30 years
- B. Use of nonsteroidal anti-inflammatories
- C. Eating foods with preservatives
- D. Past employment involving asbestos
Correct Answer: A
Rationale: Smoking is the most significant risk factor for bladder cancer, as tobacco toxins are excreted in urine, directly irritating the bladder lining.
A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?
- A. A normal blood sugar level
- B. A decreased blood sugar level
- C. An increased blood sugar level
- D. Fluctuating levels with a predawn increase
Correct Answer: C
Rationale: Hyperglycemia occurs due to glucose production in response to the stress and illness of cellulitis.
A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?
- A. Contractions every 2 minutes, lasting 100 seconds
- B. Fetal heart decelerations during a contraction
- C. Beat-to-beat variability between contractions
- D. Fetal heart decelerations at the beginning of contractions
Correct Answer: A
Rationale: These are tetanic in nature and can cause rupture of the uterus. The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. Beat-to-beat variability is a normal finding and demonstrates fetal well-being. The FHR may decrease at the beginning of a contraction owing to head compression.
The nurse who is caring for a client with cancer notes a WBC of 500/mm3 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?
- A. Assess temperature every four hours because of risk for hypothermia.
- B. Instruct the client to avoid large crowds and people who are sick.
- C. Instruct in the use of a soft toothbrush.
- D. Assess for signs of bleeding.
Correct Answer: B
Rationale: A WBC of 500/mm3 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people (B) is critical. Hypothermia (A) is not a primary concern, soft toothbrush (C) prevents bleeding, and bleeding (D) is for thrombocytopenia.