Nokea
When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, which of the following descriptions about the stoma's appearance should the nurse include in the teaching?
- A. Becoming dark brown in 2 months.
- B. Appearing moist and pink to red.
- C. Drying out within a few weeks.
- D. Shrinking significantly in size.
Correct Answer: B
Rationale: A healthy stoma is moist and pink to red, indicating good blood supply.
You may also like to solve these questions
An adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure. Based on these fi ndings, the nurse should:The chart shows:
- A. Continue monitoring intake and output.
- B. Notify the physician.
- C. Restrict the client’s fluids.
- D. Increase the client’s fluids.
Correct Answer: B
Rationale: The nurse would expect a person with a normal GFR to have approximately equal inputs and outputs. Chronic renal failure has fi ve stages. In stage I the glomerular fi ltration rate (GFR) is approximately ≥90 mL/minute/1.73 m2. In stage II the GFR decreases to approximately 60 to 89 mL/minute/1.73 m2. The decreased urine output may indicate worsening disease and should be reported. Assessing the client’s intake and output is still important, but notifying the provider is the priority. Fluids are restricted based on decreased sodium. Clients are encouraged to drink to thirst. Therefore, there is not enough information to suggest increasing or restricting fl uids.
To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to:
- A. Smile and laugh out loud.
- B. Roll from back to side.
- C. Hold a rattle briefly.
- D. Turn the head from side to side.
Correct Answer: D
Rationale: A 1-month-old can turn their head side to side, a basic motor milestone.
A 16-month-old child is seen in the clinic for a checkup for the first time. The nurse notices that the toddler limps when walking. Which of the following would be appropriate to use when assessing this toddler for developmental dysplasia of the hip?
- A. I couldn'ts maneuver.
- B. Barlow's maneuver.
- C. Adam's position.
- D. Trendelenburg's sign.
Correct Answer: B
Rationale: Barlow's maneuver is used to assess for hip instability in infants and toddlers, appropriate for detecting developmental dysplasia of the hip.
A nasogastric tube inserted during surgery to correct an infant's intussusception is no longer freely removing gastric secretions. Which of the following should the nurse do next?
- A. Aspirate the tube with a syringe.
- B. Irrigate the tube with distilled water.
- C. Increase the level of suction.
- D. Rotate the tube.
Correct Answer: A
Rationale: Aspirating with a syringe checks for blockages and attempts to restore function safely.
Which of the following should the nurse include in the discharge teaching for a parent of an infant with a repaired cleft lip to promote healing?
- A. Avoid pacifier use for 2 weeks.
- B. Apply antibiotic ointment daily.
- C. Keep the infant in a supine position.
- D. Offer large, frequent feedings.
Correct Answer: A
Rationale: Avoiding pacifier use prevents stress on the suture line, promoting healing.