Nokea
When developing the preoperative plan of care for an infant with Hirschsprung's disease, which of the following should the nurse include?
- A. Administering a tap water enema.
- B. Inserting a gastrostomy tube.
- C. Inserting a rectal tube.
- D. Using povidone-iodine solution to prepare the perineum.
Correct Answer: C
Rationale: A rectal tube may help relieve obstruction preoperatively in Hirschsprung's disease.
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A 14-year-old is being screened for scoliosis. Which of the following statements about scoliosis screening is true?
- A. Teenagers ages 14 to 16 should be screened yearly.
- B. A shirt and shorts are worn for screening.
- C. The girl is assessed standing and bending forward.
- D. The girl should refrain from eating 8 hours before the examination.
Correct Answer: C
Rationale: Assessing the girl standing and bending forward is the standard method to detect spinal asymmetry during scoliosis screening.
An adolescent girl with a seizure disorder controlled with phenytoin (Dilantin) and carbamazepine (Tegretol) asks the nurse about getting married and having children. Which of the following responses by the nurse would be most appropriate?
- A. You probably shouldn't consider having children until your seizures are cured.'
- B. Your children won't necessarily have an increased risk of seizure disorder.'
- C. When you decide to have children, talk to the doctor about changing your medication.'
- D. Women with seizure disorders commonly have a difficult time conceiving.'
Correct Answer: C
Rationale: Consulting a doctor about medication adjustments before pregnancy ensures safety for mother and fetus, addressing teratogenic risks.
To determine if a blood pressure reading is normal, the nurse must know which information about the child? Select all that apply.
- A. Age.
- B. Body mass index (BMI).
- C. A secret.
- D. Height.
- E. Occipital frontal circumference (OFC).
- F. Weight.
Correct Answer: A,D,F
Rationale: Age, height, and weight are key factors in determining normal blood pressure ranges.
The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine?
- A. A family history of sudden infant death syndrome (SIDS).
- B. A fever of 38.5°C following the 4-month vaccinations.
- C. An acute bilateral ear infection.
- D. Living with a family member who is immunosuppressed.
Correct Answer: C
Rationale: An acute infection is a contraindication for vaccination due to the risk of adverse reactions.
The mother asks the nurse whether her child with hemiparesis due to spastic cerebral palsy will be able to walk normally because he can pull himself to a standing position. Which of the following responses by the nurse would be most appropriate?
- A. Ask the doctor what he thinks at your next appointment.'
- B. Maybe, maybe not. How old were you when you first walked?'
- C. It's difficult to predict, but his ability to bear weight is a positive factor.'
- D. If he really wants to walk, and works hard, he probably will eventually.'
Correct Answer: C
Rationale: The ability to bear weight is a positive sign, but predicting normal walking is challenging due to the variability in cerebral palsy outcomes.