Nokea
The parent of a 3-month-old infant is concerned because the infant is not able to sit independently. How should the nurse respond to this parent's concern?
- A. Sitting ability and the age of first tooth eruption are not correlated.
- B. Most infants sit steadily at 4 months.
- C. Most infants sit steadily at 3 months.
- D. Most infants do not sit steadily until 6-8 months.
Correct Answer: D
Rationale: The correct answer is D because sitting steadily typically occurs closer to 6-8 months of age, not 3 or 4 months. Choice A is incorrect because sitting ability and the age of first tooth eruption are not related. Choice B and C are incorrect as most infants do not sit steadily at 3 or 4 months, and it is more common for infants to achieve this milestone around 6-8 months.
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What is a primary consideration for complications when planning nursing care for an infant with Meconium aspiration syndrome?
- A. Hypoglycemia
- B. Bowel obstruction
- C. Airway obstruction
- D. Carbon dioxide retention
Correct Answer: C
Rationale: The correct answer is C: Airway obstruction. When planning nursing care for an infant with Meconium aspiration syndrome, a primary consideration for complications is the potential of airway obstruction. After the passage of meconium into the amniotic fluid, the infant may inhale or swallow the fluid, leading to meconium aspiration into the lower airways and causing a partial airway obstruction. This can result in respiratory distress and hypoxemia. Hypoglycemia (choice A) is a metabolic condition unrelated to meconium aspiration. Bowel obstruction (choice B) with meconium may indicate other conditions like cystic fibrosis or Hirschsprung disease, not directly related to meconium aspiration syndrome. Carbon dioxide retention (choice D) is not a primary consideration in meconium aspiration syndrome; instead, the focus is on addressing the airway obstruction and potential respiratory compromise.
What illnesses does respiratory hygiene and cough etiquette by the Centers for Disease Control and Prevention (CDC) prevent?
- A. HBV, Hib, and pertussis
- B. HSV, influenza, and HBV
- C. RSV, influenza, and adenovirus
- D. RSV, pertussis, and varicella
Correct Answer: C
Rationale: The correct answer is C: RSV, influenza, and adenovirus. The CDC recommends respiratory hygiene and etiquette to prevent the transmission of respiratory syncytial virus (RSV), influenza, adenovirus, and other droplet-transmitted unknown viruses. Choices A, B, and D are incorrect because HBV, Hib, pertussis, HSV, and varicella are not typically transmitted via droplets but through other modes of transmission.
A preschool-age child is admitted to the pediatric unit for surgery. The parents request to stay with their child. How should the nurse respond?
- A. Tell the parents they can stay in the hospital but not on the unit
- B. Read the rules and regulations of rooming in with the child
- C. Let the parents know they are allowed to stay with the child
- D. Explain to the parents why they cannot stay with the child
Correct Answer: C
Rationale: The correct response is to let the parents know they are allowed to stay with the child. Allowing parents to stay with the child can help reduce the child's anxiety and provide comfort. Choice A is incorrect as the parents should be encouraged to stay with their child. Choice B is not the immediate response the nurse should provide. Choice D is inappropriate as it does not address the benefits and importance of parental presence for the child's well-being during hospitalization.
An eleven-year-old boy is admitted with a history of type 1 diabetes. What information about school age should the nurse use to formulate the teaching plan for daily injections?
- A. The parents do not need to learn the procedure.
- B. The child is old enough to give most of his injections.
- C. Self-injections will be possible when he is closer to adolescence.
- D. The child can learn about self-injections when he is able to reach all injection sites.
Correct Answer: B
Rationale: By the age of eleven, many children are capable of administering their own insulin injections with supervision, fostering independence and better management of their diabetes. This age is appropriate for the child to take on more responsibility for their care. While parental involvement is still crucial for supervision and guidance, the child can start to learn and perform the injections themselves. Choice A is incorrect because parental involvement is important for safety and proper technique. Choice C is incorrect as waiting until closer to adolescence may delay the child's ability to manage their diabetes effectively. Choice D is incorrect as reaching injection sites is not the sole criteria; proper technique and supervision are essential.
Which clinical manifestations should the nurse expect in a child diagnosed with nephroblastoma?
- A. Atrial fibrillation
- B. Endocarditis
- C. Hyperlipidemia
- D. Hypertension
Correct Answer: D
Rationale: The correct answer is D: Hypertension. Nephroblastoma, also known as Wilms' tumor, often causes hypertension due to its impact on the kidney, which plays a role in regulating blood pressure. Atrial fibrillation (choice A) and endocarditis (choice B) are not typically associated with nephroblastoma. Hyperlipidemia (choice C) is also not a common clinical manifestation of nephroblastoma.