Nokea
The parents of a 2-month-old infant, who is being discharged after treatment for pyloric stenosis, are being educated by the healthcare provider. Which statement by the parents indicates a need for further teaching?
- A. We should feed our baby in an upright position
- B. We should avoid feeding our baby solid foods until at least 6 months of age
- C. We will lay our baby on their stomach to sleep
- D. We will burp our baby frequently during feedings
Correct Answer: C
Rationale: The correct answer is C. Placing babies on their stomach to sleep increases the risk of sudden infant death syndrome (SIDS). The safest sleep position for infants is on their back to reduce the risk of SIDS. Teaching parents about safe sleep practices is crucial in preventing potential harm to the infant. Choices A, B, and D are all correct statements that promote the well-being of the infant. Feeding the baby in an upright position helps prevent reflux, delaying solid foods until 6 months of age is recommended for proper growth and development, and burping the baby frequently during feedings helps prevent gas buildup and colic.
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The child is 3 years old and is 2 hours postop from a cardiac catheterization via the right femoral artery. Which assessment finding indicates arterial obstruction?
- A. Blood pressure is decreasing, and the pulse is rapid and irregular.
- B. The right foot feels cool to the touch and appears pale and blanched.
- C. The pulse distal to the femoral artery is weaker in the left foot than the right foot.
- D. The pressure dressing at the right femoral area is damp and oozing blood.
Correct Answer: B
Rationale: A cool, pale, and blanched foot is indicative of arterial obstruction, leading to poor blood flow. This finding requires immediate intervention to prevent further complications such as tissue damage or necrosis. Monitoring for signs of arterial compromise, such as color changes, temperature, and capillary refill, is crucial in detecting and managing vascular complications post-cardiac catheterization. Choices A, C, and D do not directly indicate arterial obstruction. While a decreasing blood pressure and rapid, irregular pulse may suggest compromise, these findings are more nonspecific. A weaker pulse distal to the femoral artery indicates reduced perfusion but not necessarily arterial obstruction. Finally, a damp, oozing pressure dressing suggests a dressing issue rather than arterial obstruction.
When a 3-year-old boy asks a nurse why his baby sister is eating his mommy's breast, how should the nurse respond? (Select the response that does not apply.)
- A. Remind him that his mother breastfed him too
- B. Clarify that breastfeeding is the mother's choice
- C. Reassure the older brother that it does not hurt his mother
- D. Explain that newborns get milk from their mothers in this way
Correct Answer: A
Rationale: In this scenario, the nurse should avoid reminding the older sibling about his own breastfeeding experience as it does not directly address the question posed by the boy. Providing simple explanations about breastfeeding and newborn feeding patterns helps the older sibling understand the natural process without bringing up personal experiences. Choice B is correct because clarifying that breastfeeding is the mother's choice helps the older sibling understand the concept of personal decisions. Choice C is appropriate as reassuring the older brother that it does not hurt his mother addresses a common concern children may have. Choice D is also suitable as it explains in simple terms how newborns receive milk from their mothers.
A 10-year-old child is admitted to the hospital with a diagnosis of acute glomerulonephritis. The nurse notes that the child has edema and elevated blood pressure. What is the nurse's priority action?
- A. Administer antihypertensive medication as prescribed
- B. Monitor the child's urine output
- C. Elevate the child's legs to reduce edema
- D. Restrict the child's fluid intake
Correct Answer: A
Rationale: In a child with acute glomerulonephritis presenting with edema and elevated blood pressure, the priority action for the nurse is to administer antihypertensive medication as prescribed. Managing blood pressure is essential to prevent further complications associated with the condition, such as worsening kidney function and cardiovascular strain. Monitoring urine output is important but not the priority over managing elevated blood pressure. Elevating the child's legs may help with edema but addressing the elevated blood pressure takes precedence. Fluid intake restriction may be necessary in some cases, but it is not the immediate priority when managing acute glomerulonephritis with edema and hypertension.
When caring for a child experiencing severe asthma symptoms, which medication should the practical nurse anticipate being administered first?
- A. Inhaled corticosteroids.
- B. Oral corticosteroids.
- C. Short-acting beta agonists.
- D. Leukotriene receptor antagonists.
Correct Answer: C
Rationale: In the management of acute asthma exacerbations, the first-line medication for quick relief of bronchoconstriction is a short-acting beta agonist, such as albuterol. These medications help to rapidly open up the airways, providing immediate relief to the patient. Inhaled corticosteroids are more commonly used for long-term control of asthma symptoms, while oral corticosteroids and leukotriene receptor antagonists are often reserved for more severe or chronic cases. Therefore, in a child experiencing severe asthma symptoms, the practical nurse should anticipate the administration of short-acting beta agonists as the initial intervention to provide quick relief and improve breathing.
A 15-year-old adolescent with anorexia nervosa is admitted to the hospital for severe weight loss. The nurse notes that the client has dry skin, brittle hair, and is severely underweight. What is the nurse's priority intervention?
- A. Establish a therapeutic relationship with the client
- B. Monitor the client's vital signs frequently
- C. Initiate a structured eating plan
- D. Provide education about healthy eating habits
Correct Answer: C
Rationale: In this scenario, the priority intervention for the nurse is to initiate a structured eating plan. Anorexia nervosa is a serious eating disorder characterized by severe food restriction, which can lead to malnutrition and severe weight loss. By starting a structured eating plan, the nurse can ensure the client receives the necessary nutrition to begin the process of weight restoration and recovery. Monitoring vital signs is essential, but without addressing the nutrition deficiency, vital signs may not improve significantly. Establishing a therapeutic relationship is crucial for long-term care but may not address the immediate risk of malnutrition. Providing education about healthy eating habits is important but may not be effective initially due to the severity of the client's condition.