Nokea
The nurse would expect to withhold penicillin V (Pen-Vee-K) and notify the physician if the child had a previous allergic reaction to a medication from which drug group?
- A. Aminoglycosides
- B. Cephalosporins
- C. Macrolides
- D. Sulfonamides
Correct Answer: B
Rationale: Penicillin V is a penicillin antibiotic, and cephalosporins have a similar beta-lactam structure, which can lead to cross-reactivity in patients with penicillin allergies. Withholding penicillin and notifying the physician is necessary if the child has a cephalosporin allergy.
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The nurse is reviewing the following labor history of a postpartum mother: “Mother positive for group B streptococcal (GBS) infection at 37 weeks’ gestation. Membranes ruptured at home 14 hours before presentation to the hospital at 40 weeks’ gestation. Precipitous labor,no antibiotic given.” Considering this information the nurse should observe her 15-hour-old newborn closely for which finding?
- A. Temperature instability
- B. Pink stains in the diaper
- C. Meconium stools
- D. Presence of erythema toxicum
Correct Answer: A
Rationale: GBS infection risk increases with prolonged membrane rupture and no antibiotics with temperature instability as an early symptom. Pink stains meconium and erythema toxicum are normal.
The nurse advises the parents that, to detect possible complications of juvenile rheumatoid arthritis, the child will require which periodic evaluation?
- A. Chest X-rays
- B. Dental examinations
- C. Hearing examinations
- D. Eye examinations
Correct Answer: D
Rationale: JRA can cause uveitis, an eye inflammation that may lead to vision loss if untreated. Periodic eye examinations are essential to detect this complication early.
Which of the following statements made by the adolescent best supports the nurse's suspicion of scoliosis?
- A. My friends are getting taller faster than I am.
- B. One of my sleeves is always shorter than the other.
- C. I have a difficult time sleeping on my side at night.
- D. I have a difficult time sleeping on my side at night.
Correct Answer: B
Rationale: Uneven sleeve length suggests shoulder asymmetry, a common sign of scoliosis due to lateral spinal curvature affecting posture.
The nurse is caring for the newborn infant. The nurse should prepare to assess the newborn’s anterior fontanel by which method?
- A. Lay the infant on his or her back.
- B. Stimulate the infant to cry strongly.
- C. Feel near the parietal and occipital bones.
- D. Place the infant in a sitting position.
Correct Answer: D
Rationale: The anterior fontanel is assessed with the infant in a sitting position (45°–90°) to evaluate size and abnormalities. Supine positioning or crying may cause bulging and parietal/occipital bones locate the posterior fontanel.
The nurse admits the term newborn,who is at risk to develop neonatal abstinence syndrome (NAS) to the newborn nursery. The nurse correctly places this infant in which location?
- A. The general nursery with 15 other infants
- B. A small,well-lit nursery with two other newborns
- C. Alone in a small,darkened nursery room
- D. Right next to the charge nurse’s desk
Correct Answer: C
Rationale: Newborns with NAS require a low-stimulus environment due to withdrawal behaviors. A small darkened room alone minimizes noise and light stimulation.