Nokea
The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which of the following would be appropriate for the nurse to administer at this visit?
- A. Diphtheria, tetanus, and acellular pertussis (DTaP); Haemophilus influenzae type B (Hib); inactivated poliomyelitis vaccine (IPV); and purified protein derivative (PPD).
- B. DTaP; Hib; oral polio vaccine (OPV); and measles, mumps, and rubella (MMR).
- C. PPD, MMR, hepatitis B (hepB), and OPV.
- D. HepB, IPV, Hib, and varicella.
Correct Answer: A
Rationale: These vaccines align with catch-up schedules for a 9-month-old, except PPD, which is a test, not a vaccine.
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A three-year-old is brought into the emergency department in her mother's arms. The child's mouth is open and she is drooling and lethargic. Her mother states that she became ill suddenly within the past 2 hours. What should the nurse do first?
- A. Draw blood cultures for complete blood count.
- B. Start an intravenous line.
- C. Inspect the child's throat with a tongue blade.
- D. Maintain the child in an undisturbed, upright position.
Correct Answer: D
Rationale: The symptoms suggest possible epiglottitis, a medical emergency. Maintaining the child in an undisturbed, upright position prevents airway obstruction and is the priority action.
Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which of the following findings should alert the nurse to notify the physician immediately?
- A. A 3-cm increase in abdominal circumference.
- B. Periods of occasional fussiness.
- C. Absence of bowel sounds since surgery.
- D. Evidence of the infant's returning appetite.
Correct Answer: A
Rationale: A 3-cm increase in abdominal circumference may indicate complications like obstruction or bleeding.
The mother of a 2-year-old is concerned because the child's right eye seems to turn in toward his nose when he is tired. The nurse should:
- A. Assure the mother that this is a normal event when the child is tired.
- B. Advise the mother to continue to watch his eyes closely and if the problem persists to call the clinic.
- C. Test the child with the cover-uncover test and refer to an ophthalmologist if the test is abnormal.
- D. Explain to the mother that the child will probably outgrow the weakness and she need not be concerned.
Correct Answer: C
Rationale: The cover-uncover test can detect strabismus, which requires referral if confirmed.
A 2-year-old tells his mother he is afraid to go to sleep because 'the monsters will get him.' The nurse should tell his mother to:
- A. Allow him to sleep with his parents in their bed whenever he is afraid.
- B. Increase his activity before he goes to bed, so he eventually falls asleep from being tired.
- C. Give him a favorite cuddly animal or a blanket.
- D. Allow him to stay up an hour later with the family until he falls asleep.
Correct Answer: C
Rationale: A comfort object helps a toddler feel secure and supports self-soothing.
When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki disease, which of the following should be the priority?
- A. Taking vital signs every 6 hours.
- B. Monitoring intake and output every hour.
- C. Minimizing skin discomfort.
- D. Providing passive range-of-motion exercises.
Correct Answer: B
Rationale: Monitoring intake and output hourly is critical in Kawasaki disease to assess for fluid balance and potential cardiac complications like coronary artery involvement.