Nokea
When developing the plan of care for an infant with myelomeningocele and the parents who have just been informed of the infant's diagnosis, which action should the nurse include as the priority when the parents visit the infant for the first time?
- A. Emphasizing the infant's normal and positive features.
- B. Encouraging the parents to discuss their fears and concerns.
- C. Reinforcing the doctor's explanation of the defect.
- D. Having the parents feed their infant.
Correct Answer: A
Rationale: Highlighting normal features helps parents bond with their infant and fosters a positive perception, which is critical initially after a diagnosis.
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The nurse is assessing a neonate with suspected tracheoesophageal fistula. Which of the following findings would be most concerning?
- A. Excessive drooling.
- B. Mild cyanosis during feeding.
- C. Heart rate of 140 bpm.
- D. Temperature of 37°C.
Correct Answer: B
Rationale: Mild cyanosis during feeding indicates potential airway compromise, a critical concern in TEF.
Which of the following assessments should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?
- A. Measurement of urine specific gravity.
- B. Auscultation of bowel sounds.
- C. Inspection of the first stool passed.
- D. Measurement of gastric output.
Correct Answer: B
Rationale: Auscultating bowel sounds monitors for paralytic ileus, a critical postoperative complication.
An adolescent with insulin-dependent diabetes is being taught the importance of rotating the sites of insulin injections. The nurse should judge that the teaching was successful when the adolescent identifies which of the following as a result of using the same site?
- A. Unstruction of the fat tissue and poor absorption.
- B. Destruction of nerves and painful neuritis.
- C. Destruction of the tissue and too-rapid insulin uptake.
- D. Development of resistance to insulin and need for increased amounts.
Correct Answer: A
Rationale: Repeated injections at the same site cause lipodystrophy, leading to poor insulin absorption. Nerve damage, rapid uptake, or insulin resistance are not primary consequences.
During assessment of an adolescent who has sustained a recent thoracic spinal injury, the nurse auscultates the adolescent's abdomen. The nurse explains to the parents that this is necessary because clients with spinal cord injury often develop which of the following?
- A. Abdominal cramping.
- B. Hyperactive bowel sounds.
- C. Paralytic ileus.
- D. Profuse diarrhea.
Correct Answer: C
Rationale: Paralytic ileus is common in spinal cord injury due to autonomic disruption, necessitating abdominal assessment for bowel sounds.
The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which of the responses by the nurse would be most appropriate?
- A. You really shouldn't leave right now. Your child is very sick.
- B. I understand, but feel free to visit or call anytime to see how your child is doing.
- C. It really isn't necessary to stay with your child. We'll take very good care of him.
- D. Can you find someone to stay with your children? Your child needs you here.
Correct Answer: B
Rationale: This response acknowledges the mother's constraints while encouraging involvement.