Nokea
The nurse reports to the physician signs of increased intracranial pressure in an infant with a myelomeningocele who has which of the following?
- A. A high-pitched cry.
- B. Overflow voiding only.
- C. A fontanel that bulges with crying.
Correct Answer: A
Rationale: A high-pitched cry is a classic sign of increased intracranial pressure in infants, indicating neurological distress. Overflow voiding and a fontanel bulging only with crying are less specific.
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When preparing to obtain a neonatal screening test for phenylketonuria (PKU), the neonate must have received which of the following to ensure reliable results?
- A. A feeding of an iron-rich formula.
- B. Nothing by mouth for 4 hours before the test.
- C. Initial formula or breast milk at least 24 hours before the test.
- D. A feeding of glucose water.
Correct Answer: C
Rationale: PKU screening requires protein intake (breast milk or formula) for 24 hours to detect elevated phenylalanine levels. Iron-rich formula, fasting, or glucose water are inadequate.
A child is started on a soft diet after having been on clear liquids following an episode of severe gastroenteritis. When helping the mother choose foods for her child, which of the following foods would be most appropriate?
- A. Muffins and eggs.
- B. Bananas and rice.
- C. Bran cereal and a bagel.
- D. Pancakes and sausage.
Correct Answer: B
Rationale: Bananas and rice are gentle on the gut, suitable for a soft diet.
A 9-month-old child with cystic fibrosis does not like to take a pancreatic enzyme supplement with meals and snacks. The mother does not like to force the child to take the supplement. The most important reason for the child to take the pancreatic enzyme supplement with meals and snacks is:
- A. The child will become dehydrated if the supplement is not taken with meals and snacks.
- B. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins.
- C. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear.
- D. The child will experience severe diarrhea if the supplement is not taken as prescribed.
Correct Answer: B
Rationale: Pancreatic enzyme supplements are essential in cystic fibrosis to aid digestion and absorption of fats, carbohydrates, and proteins, compensating for pancreatic insufficiency.
The health care provider has ordered a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family:
- A. I will request an order for a sedative to help him relax.
- B. I can't do anything to reduce the pain
- C. but you can hold him during the procedure.
- D. I will get an order for a lidocaine-based lubricant to make the procedure more comfortable.
- E. I can apply a topical anesthetic 20 minutes before placing the catheter.
Correct Answer: D
Rationale: Topical anesthetics can minimize discomfort.
An infant has been transferred from the ICU to the pediatric floor after undergoing surgery to correct a heart defect. Which tasks can the nurse delegate to the licensed practical nurse (LPN)?
- A. Administering oral medications.
- B. Administering I.V. morphine.
- C. Obtaining vital signs.
- D. Recording the input and output.
- E. Administering blood products.
- F. Morning hygiene.
- G. Circulation checks.
Correct Answer: A,C,D,F,G
Rationale: LPNs can handle oral medications, vital signs, input/output, hygiene, and circulation checks. I.V. morphine and blood products require RN oversight.