Nokea
The nurse is teaching the parents of an infant with pyloric stenosis about postoperative care. Which instruction should be included?
- A. Resume regular formula immediately.
- B. Monitor for projectile vomiting.
- C. Keep the incision site covered with a bandage.
- D. Administer pain medication every 6 hours.
Correct Answer: B
Rationale: Monitoring for projectile vomiting ensures early detection of surgical complications.
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When developing the teaching plan for parents using the Pavlik harness with their child, what should be the nurse's initial step?
- A. Assessing the parents' current coping strategies.
- B. Determining the parents' knowledge about the device.
- C. Providing the parents with written instructions.
- D. Giving the parents a list of community resources.
Correct Answer: B
Rationale: Determining the parents' knowledge about the Pavlik harness is the initial step to tailor teaching to their understanding and needs.
A parent asks, 'Can I get head lice too?' The nurse indicates that adults can also be infested with head lice but that pediculosis is more common among school children, primarily for which of the following reasons?
- A. An immunity to pediculosis usually is established by adulthood.
- B. School-age children tend to be more neglectful of frequent handwashing.
- C. Pediculosis usually is spread by close contact with infested children.
- D. The skin of adults is more capable of resisting the invasion of lice.
Correct Answer: C
Rationale: Close contact in school settings facilitates lice transmission among children.
Which of the following would be most appropriate for the nurse to teach the mother of a 6-month-old infant hospitalized with severe diarrhea to help her comfort her infant who is fussy?
- A. Offering a pacifier.
- B. Placing a mobile above the crib.
- C. Sitting at crib side talking to the infant.
- D. Turning the television on to cartoons.
Correct Answer: A
Rationale: A pacifier provides non-nutritive sucking, soothing a fussy infant.
The charge nurse on the pediatric floor has assigned a 6-year-old girl of Arab-American ethnicity with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-immune treatment. The 6-year-old's mother is upset because the parent staying with the other child is the father. The nurse should:
- A. Explain to the parents that this room arrangement facilitates teaching.
- B. Reassign the children to different rooms.
- C. Offer the Arab-American parent another place to sleep.
- D. Refer the parent to the customer service representative.
Correct Answer: B
Rationale: Cultural sensitivity requires addressing the mother's discomfort, likely due to gender norms. Reassigning rooms respects her concerns while maintaining care. Teaching convenience, alternative sleeping, or customer service do not address cultural needs.
The nurse is discharging an 8-month-old who weighs 15 lb from the hospital. The parents have put the child in the back seat of the car with the car seat facing the front. The nurse should:
- A. Ask the parents to wait while obtaining the correct car seat.
- B. Complete the discharge with the child sitting facing the front seat.
- C. Give the parents a manual on proper car seat placement.
- D. Explain the need for the rear-facing position and request assistance from a car seat technician.
Correct Answer: D
Rationale: Rear-facing car seats are recommended for infants under 2 years to protect their neck and spine.