Nokea
The physician orders an I.V. opioid analgesic. Which finding by the nurse would best indicate that the I.V. opioid analgesic is effective?
- A. The respiratory rate is within normal limits.
- B. The child's pain level remains stable.
- C. The child is watching television.
- D. The urine output is 30 mL/hour.
Correct Answer: C
Rationale: A child watching television suggests they are comfortable and distracted from pain, indicating effective pain relief from the opioid. Stable pain levels or normal respiratory rate do not directly confirm pain control.
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A 24 years old G3P2 presents to you at 32 weeks of gestation with preterm prelabour rupture of membranes for ten days. She is complaining of pain in lower abdomen,fever with rigors and chills and purulent vaginal discharge. What is her diagnosis:
- A. Pyrexia of unknown origin.
- B. Puerperal pyrexia.
- C. Preterm labour.
- D. Chorioamnionitis.
- E. Antepartum haemorrhage.
Correct Answer: D
Rationale: Chorioamnionitis is an infection of the amniotic membranes often following prolonged rupture of membranes presenting with fever abdominal pain and purulent discharge. Other options do not fit the clinical picture.
If the child weighs 30 kg, what is the hourly flow rate in milliliters? Use the standard 100 mL/kg/day for the first 10 kg of body weight, 50 mL/kg/day for the next 10 kg of body weight, and 20 mL/kg/day for each kilogram above 20 kg of body weight for daily maintenance.
Correct Answer: 70.83 mL/hour
Rationale: Calculation: First 10 kg = 100 mL/kg/day × 10 = 1000 mL/day; Next 10 kg = 50 mL/kg/day × 10 = 500 mL/day; Last 10 kg = 20 mL/kg/day × 10 = 200 mL/day. Total = 1000 + 500 + 200 = 1700 mL/day. Hourly rate = 1700 ÷ 24 = 70.83 mL/hour. Since no exact option is provided, the closest reasonable answer is assumed as correct based on standard practice.
The nurse is assessing the full-term Caucasian infant who is 40 hours old. Which technique should the nurse use to evaluate the infant for jaundice?
- A. Remove the infant’s diaper and look at the color of the genitalia.
- B. Apply pressure on the forehead for 3 seconds,release and evaluate the skin color.
- C. Assess the color of the palms and compare that skin color to the color of the soles.
- D. Open the infant’s mouth to assess the color of the infant’s tongue and palate.
Correct Answer: B
Rationale: To differentiate jaundice from normal skin color apply pressure over a bony area like the forehead. A yellow blanched area indicates jaundice. Genitalia palms soles or oral mucosa are less reliable due to slower progression or darker pigmentation.
Which nursing action is most appropriate at this time?
- A. Recognize that the fluid is cerebrospinal fluid (CSF) and remove the dressing, observing for the source of the leakage.
- B. Recognize that the fluid is CSF and call the chaplain because death of the child is imminent.
- C. Recognize that the fluid is CSF and notify the operating room because additional surgery will be necessary.
- D. Recognize that the fluid is CSF and reinforce the dressing until the physician can change it.
Correct Answer: D
Rationale: Clear drainage on a head dressing post-craniotomy is likely CSF, indicating a leak. Reinforcing the dressing prevents infection and maintains a sterile barrier until the physician assesses the leak.
The nurse is measuring both the chest and head circumference during the full-term newborn’s initial assessment. The newborn’s father observes this and asks the nurse why both measurements are necessary. Which explanation is most accurate?
- A. “Comparing the measurements helps determine if there are head or chest size abnormalities.”
- B. “Measuring the head circumference provides information about future intellectual ability.”
- C. “Measuring the newborn’s chest provides needed information when assessing cardiac health.”
- D. “Comparing the head and chest measurements helps to determine future adult body size.”
Correct Answer: A
Rationale: The circumference of the normal newborn’s head is approximately 2 centimeters greater than the chest at birth. Extreme differences may indicate abnormalities like microcephalus or hydrocephalus. Head size doesn’t predict intelligence chest size doesn’t assess cardiac health and measurements don’t predict adult size.