Nokea
When teaching the mother of an infant who has undergone surgical repair of a cleft lip how to care for the suture line, the nurse demonstrates how to remove formula and drainage. Which of the following solutions should the nurse use?
- A. Mouthwash.
- B. Povidone-iodine (Betadine) solution.
- C. A mild antiseptic solution.
- D. Half-strength hydrogen peroxide.
Correct Answer: D
Rationale: Half-strength hydrogen peroxide is gentle and effective for cleaning the suture line without irritating the delicate tissue.
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Which of the following behaviors exhibited by the parents of an infant with pyloric stenosis should the nurse correctly interpret as a positive indication of parental coping?
- A. Telling the nurse that they have to get away for a while.
- B. Discussing the infant's care realistically.
- C. Repeatedly asking if their child is normal.
- D. Exhibiting fear that they will disturb the infant.
Correct Answer: B
Rationale: Realistic discussion of care indicates acceptance and engagement with the situation.
An adolescent with a history of surgical repair for an undescended testis comes to the clinic for a sports physical. Anticipatory guidance for the parents and adolescent should focus on which of the following as most important?
- A. The adolescent's sterility.
- B. The adolescent's future plans.
- C. Technique for monthly testicular self-examinations.
- D. Need for a lot of psychological support.
Correct Answer: C
Rationale: Monthly self-exams help detect issues early.
The charge nurse on the pediatric floor has assigned a 6-year-old girl of Arab-American ethnicity with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-immune treatment. The 6-year-old's mother is upset because the parent staying with the other child is the father. The nurse should:
- A. Explain to the parents that this room arrangement facilitates teaching.
- B. Reassign the children to different rooms.
- C. Offer the Arab-American parent another place to sleep.
- D. Refer the parent to the customer service representative.
Correct Answer: B
Rationale: Cultural sensitivity requires addressing the mother's discomfort, likely due to gender norms. Reassigning rooms respects her concerns while maintaining care. Teaching convenience, alternative sleeping, or customer service do not address cultural needs.
When developing the plan of care for a school-age child with a suspected diagnosis of appendicitis who is complaining of severe abdominal pain, which of the following measures should the nurse expect to include in the child's plan of care?
- A. Application of a heating pad.
- B. Insertion of a rectal tube.
- C. Application of an ice bag.
- D. Administration of an intravenous narcotic.
Correct Answer: C,D
Rationale: Ice and narcotics relieve pain without risking perforation, unlike heat or rectal tubes.
A school-age boy with a spinal cord injury is moved to the rehabilitation unit. The nurse notes that the child tends to refuse to cooperate in care and is quiet. The nurse interprets this behavior as indicative of which of the following?
- A. A stage of grief reaction.
- B. A phase of rebellion.
- C. A reaction to sensory overload.
- D. A response to too much attention.
Correct Answer: A
Rationale: Refusal and withdrawal are consistent with grief, reflecting the child's adjustment to significant loss of function.