Nokea
The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. What knowledge should the nurse's response should be based?
- A. Unacceptable because of the risk of sudden infant death syndrome (SIDS)
- B. Unacceptable because it does not encourage achievement of developmental milestones
- C. Acceptable to encourage fine motor development
- D. Acceptable to encourage head control and turning over
Correct Answer: D
Rationale: The correct knowledge that the nurse's response should be based on is that it is acceptable to encourage head control and turning over. At 3 months of age, encouraging the infant to be prone while awake can help promote the development of head control, neck strength, and eventually facilitate the ability to turn over. This practice is considered safe and beneficial for infants within the appropriate age range, as long as the infant is supervised during the awake period. It is important to promote safe sleep practices for infants to reduce the risk of Sudden Infant Death Syndrome (SIDS), but allowing supervised tummy time for an awake infant is beneficial for their motor development.
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Hemodynamic monitoring by means of a multilumen pulmonary artery catheter can provide detailed information about:
- A. Preload
- B. Afterload
- C. Cardiac output
- D. All of the above
Correct Answer: D
Rationale: A multilumen pulmonary artery catheter, also known as a Swan-Ganz catheter, is used for advanced hemodynamic monitoring. It is inserted through a central line and positioned in the pulmonary artery to provide detailed information about various hemodynamic parameters including preload, afterload, and cardiac output.
An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority of care is to
- A. clean the umbilical cord with Betadine to prevent infection
- B. give the baby a bath
- C. call the laboratory to collect a PKU screening test
- D. check the baby's serum glucose level and administer glucose if < 40 mg/dL
Correct Answer: D
Rationale: The priority of care when a baby born to an insulin-dependent diabetic mother is brought to the nursery is to check the baby's serum glucose level and administer glucose if it is less than 40 mg/dL. Babies born to diabetic mothers, especially those with poorly controlled blood sugar levels, are at risk for hypoglycemia (low blood sugar) due to the sudden drop in glucose supply after delivery. Hypoglycemia can be dangerous for newborns and can lead to serious complications if left untreated. Therefore, monitoring the baby's serum glucose levels and providing appropriate intervention, such as administering glucose if necessary, is critical to ensure the baby's well-being.
During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
- A. Recommending that the client discontinue chemotherapy
- B. Providing a solution of hydrogen peroxide and water for use as a mouth rinse
- C. monitoring the client's platelet and leukocyte counts
- D. Checking regularly for signs and symptoms of stomatitis
Correct Answer: B
Rationale: Providing a solution of hydrogen peroxide and water for use as a mouth rinse is most likely to decrease the pain of stomatitis. Stomatitis is inflammation of the oral mucous membranes and can be quite painful for oncology clients undergoing chemotherapy. Using a solution of hydrogen peroxide and water as a mouth rinse can help reduce the risk of infection and promote healing of the mucous membranes, thereby decreasing the pain associated with stomatitis. This intervention helps to maintain oral hygiene and prevent further complications, making it an effective way to manage the client's symptoms while undergoing chemotherapy. It is important to note that discontinuing chemotherapy would not be a recommended intervention as it is the primary treatment for the client's cancer. Monitoring platelet and leukocyte counts and checking for signs and symptoms of stomatitis are important aspects of care, but providing a mouth rinse would directly address the pain and discomfort experienced by the client.
An 8-day-old is admitted with vomiting and dehydration. His HR is 170, RR is 44, BP is 85/52, and T is 99°F. The parents ask if these vital signs are normal. Which is the best response?
- A. The BP is elevated.
- B. The temperature is elevated.
- C. The heart rate is elevated; normal for a neonate is 90-160 bpm.
- D. The respiratory rate is elevated.
Correct Answer: C
Rationale: A neonatal heart rate of 170 is above the normal range (90-160 bpm), which is concerning for dehydration.
The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. What should the nurse recommend?
- A. Never heat a bottle in a microwave oven.
- B. Heat only 10 ounces or more.
- C. Always leave bottle top uncovered to allow heat to escape.
- D. Shake bottle vigorously for at least 30 seconds after heating.
Correct Answer: A
Rationale: The nurse should recommend never heating a bottle in a microwave oven. Microwaves do not heat liquids evenly, and there is a risk of creating hot spots in the formula, which can burn the baby's mouth and throat. It is safer to heat the formula by placing the bottle in warm water or using a bottle warmer to ensure uniform heating throughout.