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What action should the nurse take to assess the pharyngeal reflex on a child?
- A. Ask the client to swallow.
- B. Pull down on the lower eyelid.
- C. Shine a light toward the bridge of the nose.
- D. Stimulate the back of the throat with a tongue depressor.
Correct Answer: D
Rationale: The pharyngeal (gag) reflex is tested by touching the back of the throat with an object, such as a tongue depressor. A positive response to this reflex is considered normal. Asking the client to swallow assesses the swallowing reflex. To assess the palpebral conjunctiva, the nurse would pull down and evert the lower eyelid. The corneal light reflex is tested by shining a penlight toward the bridge of the nose at a distance of 12 to 15 inches (light reflection should be symmetrical in both corneas).
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After assisting with a vaginal delivery, what should the nurse do to prevent heat loss via conduction in the newborn?
- A. Wrap the newborn in a blanket.
- B. Close the doors to the delivery room.
- C. Dry the newborn with a warm blanket.
- D. Place the newborn on a warm crib pad.
Correct Answer: D
Rationale: Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. Warming the crib pad will assist in preventing hypothermia by conduction. Radiation occurs when heat from the newborn radiates to a colder surface. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth will prevent hypothermia via evaporation.
The nurse is preparing to assess the respirations of several newborns in the nursery. The nurse performs the procedure and determines that the respiratory rate is normal if which finding is noted?
- A. A respiratory rate of 30 breaths per minute in a crying newborn
- B. A respiratory rate of 46 breaths per minute in an awake newborn
- C. A respiratory rate of 60 breaths per minute in a sleeping newborn
- D. A respiratory rate of 76 breaths per minute in a newly delivered newborn
Correct Answer: B
Rationale: Normal respiratory rate varies from 30 to 50 breaths per minute when the infant is not crying. Respirations should be counted for 1 full minute to ensure an accurate measurement because the newborn infant may be a periodic breather. Observing and palpating respirations while the infant is quiet promotes accurate assessment.
A low dose of ondansetron is prescribed for a client receiving chemotherapy. The nurse anticipates that the primary health care provider will prescribe the medication by which route?
- A. Oral
- B. Intranasal
- C. Intravenous
- D. Subcutaneous
Correct Answer: C
Rationale: Ondansetron is an antiemetic used to control nausea, vomiting, and motion sickness. It is available for administration by the oral, intramuscular (IM), or intravenous (IV) routes. The IV route is the route used when relief of nausea is needed in the client receiving chemotherapy. The IM route may be used when the medication is used as an adjunct to anesthesia. Option 1 should not be used in clients who are nauseated. Options 2 and 4 are not routes of administration of this medication.
A client has received atropine sulfate preoperatively. The nurse monitors the client for which effect of the medication in the immediate postoperative period?
- A. Diarrhea
- B. Bradycardia
- C. Urinary retention
- D. Excessive salivation
Correct Answer: C
Rationale: Atropine sulfate is an anticholinergic medication that causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, and urinary retention. The nurse should monitor the client for any of these effects in the immediate postoperative period. None of the other options relate to this medication.
A visiting home care nurse finds a client unconscious in the bedroom. The client has a history of abusing the selective serotonin reuptake inhibitor, sertraline. The nurse should immediately conduct which assessment?
- A. Pulse
- B. Respirations
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: In an emergency situation, the nurse should determine breathlessness first and then assess for a pulse. Blood pressure would be assessed after these assessments are performed. Urinary output is also important but is not the priority at this time.