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When explaining to parents how to reduce the risk of Sudden Infant Death Syndrome (SIDS) the nurse should teach about which of the following measures? Select all that apply.
- A. Maintain a smoke-free environment.
- B. Use a wedge for side-lying positions.
- C. Breast-feed the baby.
- D. Place the baby on his back to sleep.
- E. Use bumper pads over
- F. Have the baby sleep in the parent's bed.
Correct Answer: A,C,D
Rationale: Maintaining a smoke-free environment, breastfeeding, and placing the baby on his back to sleep are evidence-based measures to reduce SIDS risk. Side-lying positions, bumper pads, and bed-sharing increase SIDS risk and should be avoided.
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A 10-year-old has 5 lb of Buck's extension traction on his left leg. The nurse should assess the child for which of the following? Select all that apply.
- A. Dryness of the skin, by removing the foam wraps and boot.
- B. Alignment of the shoulder, hips, and knees.
- C. Frayed rope near pulleys.
- D. Correct amount of traction weight on fracture.
- E. Pressure on the coccyx.
Correct Answer: B,C,D,E
Rationale: The nurse should check alignment, rope condition, weight accuracy, and pressure points to ensure effective and safe traction.
The mother of a toddler hospitalized for episodes of diarrhea reports that when her toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I don't know what to do?" After teaching the mother about ways to manage this behavior, which of the following statements indicates that the nurse's teaching was successful?
- A. Next time she screams and throws her legs, I'll ignore the behavior.
- B. I'll allow her to have what she wants once in a while.
- C. I'll explain why she cannot have what she wants.
- D. When she behaves like this, I'll tell her that she is being a bad girl.
Correct Answer: A
Rationale: Ignoring tantrums reinforces calm behavior without rewarding outbursts.
Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine?
- A. What they know about the legal implications of drinking.
- B. The type of alcohol they usually drink.
- C. The reasons they choose to use alcohol.
- D. When and with whom they use alcohol.
Correct Answer: C
Rationale: Understanding the reasons for alcohol use helps address underlying issues and tailor interventions.
Which of the following should the nurse expect to observe in an infant with intussusception before surgical intervention?
- A. Fever and lethargy.
- B. Currant jelly stools.
- C. Frequent loose stools.
- D. Increased appetite.
Correct Answer: B
Rationale: Currant jelly stools are a classic sign of intussusception due to mucosal bleeding.
A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should:
- A. Place a pillow under the child's buttocks to provide support.
- B. Remove the weight from the left leg.
- C. Assess the feet for signs of neurovascular impairment.
- D. Reposition the pulleys so the traction is looser.
Correct Answer: C
Rationale: Assessing for neurovascular impairment is critical, as pain could indicate compromised circulation or nerve function.