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A nurse is preparing to take a rectal temperature on a 7-month-old infant. Which of the following should the nurse keep in mind when preparing to take the temperature?
- A. A well-lubricated thermometer tip should be inserted a maximum of 2.5 in into the rectum.
- B. A rectal temperature of 99.6° F is equal to an oral temperature of 97.7° F.
- C. Infants should have temperatures taken rectally for accuracy and thermoregulation.
- D. Mercury thermometers are the thermometers of choice to obtain the rectal temperature, holding it in place for 4 min.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The correct answer is B because rectal temperatures are typically 1.5-2°F higher than oral temperatures due to the body's core temperature being higher internally. This conversion is essential in accurately interpreting the infant's rectal temperature.
Summary of other choices:
A: Incorrect. The maximum insertion depth for a rectal thermometer in infants is 1 inch, not 2.5 inches.
C: Incorrect. Rectal temperatures are not the only accurate method for infants; axillary or temporal artery thermometers are also reliable.
D: Incorrect. Mercury thermometers are no longer recommended due to the risk of mercury exposure, and the time required to obtain a rectal temperature is typically shorter.
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Which treatment is a nursing priority when providing care for an infant diagnosed with bacterial meningitis?
- A. Initiate cardiorespiratory monitoring.
- B. Initiate intravenous fluids.
- C. Observe respiratory isolation.
- D. Administer antibiotic therapy.
Correct Answer: D
Rationale: The first nursing priority is the implementation of antibiotic therapy, which prohibits the microbial damage to the neurologic system through the cerebral spinal fluid. Immediate treatment with antibiotics can prevent serious complications such as death, deafness, reduced cognitive ability, and seizures.
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, ''happy one min and crying the next.'' The nurse should interpret the client's statement as an indication of which of the following?
- A. Emotional lability
- B. Focusing phase
- C. Cognitive restructuring
- D. Couvade syndrome
Correct Answer: A
Rationale: The correct answer is A: Emotional lability. Emotional lability refers to rapid, unpredictable changes in emotions. During pregnancy, hormonal fluctuations can lead to mood swings, causing the client to feel happy one minute and crying the next. Focusing phase (B) is not relevant to the client's emotional state. Cognitive restructuring (C) involves changing negative thought patterns, which is not mentioned in the scenario. Couvade syndrome (D) is a condition where male partners experience pregnancy-like symptoms, which is not applicable here.
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
- A. I should not remove the yellow exudate on the end of the penis.
- B. I will clean his penis with each diaper change.
- C. The circumcision will heal completely within a couple of weeks.
- D. I can give him a tub bath in two days.
Correct Answer: D
Rationale: The correct answer is D: "I can give him a tub bath in two days." This statement indicates the need for further clarification because newborns who have undergone circumcision should avoid submerging the area in water until it is fully healed to prevent infection. Tub baths should be avoided until the circumcision site has completely healed, which usually takes about 7-10 days. It is important to keep the area clean and dry during this time to promote healing.
Explanation for other choices:
A: "I should not remove the yellow exudate on the end of the penis." - Correct, as it is normal and part of the healing process.
B: "I will clean his penis with each diaper change." - Correct, as keeping the area clean helps prevent infection.
C: "The circumcision will heal completely within a couple of weeks." - Correct, as the healing process typically takes around 1-2 weeks.
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
- A. Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
- B. Numerous clots are abnormal and should be reported to the physician.
- C. Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
- D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkishbrown, to creamy white.
Correct Answer: D
Rationale: The correct answer is D. Lochia normally lasts for about 21 days, and changes from bright red to pinkish-brown to creamy white. This is accurate because the process of lochia flow typically follows this pattern as the uterus sheds its lining post-delivery. Lochia rubra occurs in the first few days due to blood, then transitions to serosa and alba as the bleeding decreases. Choice A is incorrect as it presents the correct information but in a confusing manner. Choices B and C are incorrect because they focus on abnormal findings rather than the normal progression of lochia.
A postterm infant is delivered by cesarean section because of fetal distress and meconium-stained amniotic fluid. The nursery nurse frequently monitors the baby's respiratory rate, observing for tachypnea. Which is the reason for the nurse's actions? The infant may:
- A. experience respiratory depression from the medications used during delivery
- B. develop meconium aspiration pneumonia
- C. have an elevated temperature
- D. have a pneumothorax related to delivery
Correct Answer: B
Rationale: The correct answer is B: develop meconium aspiration pneumonia. Meconium-stained amniotic fluid can lead to the infant inhaling meconium, which can cause blockage and inflammation in the airways, leading to meconium aspiration pneumonia. This can result in respiratory distress, tachypnea, and potential complications like respiratory failure. The nurse monitors the respiratory rate to detect any signs of respiratory distress early on.
Incorrect choices:
A: Respiratory depression from medications used during delivery is less likely to be the cause of tachypnea in this scenario.
C: Elevated temperature is not directly related to meconium aspiration pneumonia or respiratory distress in this case.
D: A pneumothorax related to delivery is possible but less likely than meconium aspiration pneumonia as the cause of tachypnea in this case.