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What findings would the nurse consider normal in assessing the anterior fontanel of a neonate?
- A. Closed anterior fontanel
- B. Sunken anterior fontanel
- C. Bulging anterior fontanel
- D. Pulsating anterior fontanel
Correct Answer: D
Rationale: The correct answer is D: Pulsating anterior fontanel. The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel, which is a normal finding in a neonate. A closed anterior fontanel, as mentioned, is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality. Therefore, options A, B, and C are considered abnormal findings when assessing the anterior fontanel of a neonate.
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The nurse is caring for a 2-year-old child in the postoperative period. Which pain assessment tool is most appropriate for assessing pain intensity in a 2-year-old?
- A. Poker chip tool
- B. Oucher Scale
- C. Faces Pain Rating Scale
- D. FLACC Behavioral Pain Assessment Scale
Correct Answer: D
Rationale: The FLACC Behavioral Pain Assessment Scale is the most suitable tool for assessing pain in 2-year-old children postoperatively. It assesses pain by evaluating facial expression, leg movement, activity, cry, and consolability, making it effective for non-verbal children. The Poker chip tool is not appropriate for this age group. The Oucher Scale and Faces Pain Rating Scale are more suitable for older children who can self-report pain levels.
The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?
- A. Appropriate because of the child's age
- B. Appropriate, but the mother may be uncomfortable
- C. Inappropriate because of the child's age
- D. Inappropriate because the child is the same sex as the mother
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?
- A. The dorsal gluteal muscle
- B. The vastus lateralis muscle
- C. The ventral gluteal muscle
- D. The biceps muscle
Correct Answer: B
Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.
What interventions would the nurse implement to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid using alkaline-based soap.
- B. Bathe the infant with sterile water.
- C. Cleanse skin with a gentle alkaline-based soap and water.
- D. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
Correct Answer: B
Rationale: To maintain the skin integrity of a preterm infant born at 30 weeks, the nurse should bathe the infant with sterile water no more than two or three times per week. The eyes, oral and diaper areas, and pressure points should be cleansed daily. It is essential to avoid using alkaline-based soaps as they might destroy the 'acid mantle' of the skin. Additionally, cleansing with mild solutions and rinsing thoroughly with plain water is recommended to prevent skin irritation and maintain skin integrity. Therefore, options A, C, and D are incorrect as they do not align with the best practices for preterm infant skin care.
The nurse is testing an infant's visual acuity. By which age should the infant be able to fix on and follow a target?
- A. 1 month
- B. 1 to 2 months
- C. 3 to 4 months
- D. 6 months
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.