Nokea
When performing a physical examination on an infant, the nurse in charge notes abnormally low- set ears. This finding is associated with:
- A. Otogenous tetanus
- B. Tracheoesophageal fistula
- C. Congenital heart defects
- D. Renal anomalies
Correct Answer: C
Rationale: Abnormally low-set ears are often associated with certain congenital anomalies, including congenital heart defects. When a nurse notes this finding during a physical examination of an infant, it is important to consider the possibility of congenital anomalies and further assessment for associated conditions. Low-set ears alone are not diagnostic of a specific congenital heart defect, but they can serve as a clue to support the need for further evaluation to rule out any underlying cardiac issues. Other congenital anomalies that may be associated with low-set ears include renal anomalies, which makes option D a distractor in this case.
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Which term refers to a newborn born before completion of week 37 of gestation, regardless of birth weight?
- A. Postterm
- B. Preterm
- C. Low birth weight
- D. Small for gestational age
Correct Answer: B
Rationale: The term "preterm" refers to a newborn born before completion of week 37 of gestation, regardless of birth weight. Preterm birth can lead to various health issues for the newborn, as they may not have fully developed before being born. It is important for healthcare providers to closely monitor preterm infants to ensure they receive the proper care and support for their development.
A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600mg PO every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs?
- A. Dysuria
- B. Tinnitus
- C. Leg cramps
- D. Constipation
Correct Answer: B
Rationale: Tinnitus is a known adverse drug reaction to aspirin, especially at higher doses. Tinnitus is described as ringing, buzzing, or other noises in the ears. If a client experiences tinnitus while taking aspirin, it is important to notify the physician promptly as it could be a sign of aspirin toxicity. Monitoring and managing this adverse reaction are crucial to prevent further complications for the client.
Nurse Kevin is assessing a newborn for developmental dysplasia of the hip (DDH); he would expect to assess which of the following?
- A. Characteristic limp
- B. Ortolani's sign
- C. Symmetrical gluteal folds
- D. Trendelenburg‘s signs
Correct Answer: B
Rationale: Developmental dysplasia of the hip (DDH) is a condition where the hip joint does not properly form in babies and young children. To assess for DDH, healthcare professionals like Nurse Kevin utilize the Ortolani test. Ortolani's sign is a physical exam maneuver where the healthcare provider will gently manipulate the baby's hips to detect if there is a dislocated hip joint. Specifically, the Ortolani maneuver checks for the presence of a "clunk" as the femoral head relocates into the acetabulum, indicating that the hip joint is dislocated. Therefore, during the assessment of a newborn for DDH, Nurse Kevin would expect to assess for Ortolani's sign as it helps in the diagnosis of developmental dysplasia of the hip.
Clients with myastherda gravis, Guillain - Barre Syndrome or amyothrophic sclerosis experience:
- A. Progressive deterioration until death
- B. Deficiencies of essential neurotransmitter
- C. Increased risk of respiratory complications
- D. Involuntary twitching of small muscle group
Correct Answer: C
Rationale: Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis (ALS) are all affected by various neuromuscular conditions that can lead to respiratory complications. These conditions can cause weakness in the muscles involved in breathing, leading to difficulties with coughing, clearing secretions, and maintaining adequate ventilation. This weakness can ultimately result in an increased risk of breathing difficulties, respiratory infections, and respiratory failure. Therefore, clients with these conditions require close monitoring and respiratory support to manage and prevent complications related to respiratory function.
An infant has been pronounced dead from sudden infant death syndrome (SIDS) in the emergency department. Which is an appropriate question to ask the parents?
- A. "Did you hear the infant cry out?"
- B. "Why didn't you check on the infant earlier?"
- C. "What time did you find the infant?"
- D. "Was the head buried in a blanket?"
Correct Answer: C
Rationale: This is an appropriate question to ask the parents because determining the time the infant was found is important for investigating the circumstances surrounding the sudden infant death syndrome (SIDS) event. Understanding the timeline can help healthcare providers gather valuable information to determine the cause of death and evaluate any potential contributing factors. This question also allows the healthcare team to better understand the sequence of events leading up to the tragic outcome and offer support to the grieving parents. Asking about the time the infant was found is non-accusatory and focuses on gathering relevant details for the medical evaluation.