Nokea
When the infant returns to the unit after imperforate anus repair, the nurse should place the infant in which of the following positions?
- A. On the abdomen, with legs pulled up under the body.
- B. On the back, with legs extended straight out.
- C. Lying on the side with the hips elevated.
- D. Lying on the back in a position of comfort.
Correct Answer: C
Rationale: Lying on the side with hips elevated minimizes pressure on the surgical site and promotes healing.
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Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?
- A. A drop in blood pressure.
- B. An increase in temperature.
- C. Auscultation of moist crackles.
- D. Marked increase in urine output.
Correct Answer: C
Rationale: Moist crackles indicate fluid in the lungs, a sign of circulatory overload.
The nurse is assessing an 11-year-old female, using the Tanner Staging of Puberty. Which of the following indicates preadolescent development of the breasts?
- A. Tanner-1.png
- B. Tanner-2.png
- C. Tanner-3.png
- D. Tanner-4.png
Correct Answer: C
Rationale: This figure indicates elevation of the papilla, without breast buds, considered Stage 1 and typical of a preadolescent. Figure 1 shows stage 2, breast bud enlargement; there is elevation of the breast and the diameter of the areola has increased. Figure 2 shows stage 3, enlargement of the breast and areola. Figure 4 shows stage 4, in which there is projection of areola and papilla to form a secondary mound above the level of the breast
After discussing asthma as a chronic condition, which of the following statements by the father of a child with asthma best reflects the family's positive adjustment to this aspect of the child's disease?
- A. I try to keep him happy at all costs; otherwise, he has an asthma attack.
- B. We keep our child away from other children to help cut down on infections.
- C. Although our child's disease is serious, we try not to let it be the focus of our family.
- D. I'm afraid that when my child gets older, he won't be able to care for himself like I do.
Correct Answer: C
Rationale: The statement 'Although our child's disease is serious, we try not to let it be the focus of our family' reflects a positive adjustment, indicating the family is managing the chronic condition without letting it dominate their lives.
The nurse is assessing a child with sickle cell disease during a routine clinic visit. Which finding requires immediate follow-up by the nurse?
- A. Pallor of the nail beds and mucous membranes.
- B. A heart rate of 88 beats per minute.
- C. Intact and equal bilateral peripheral pulses.
- D. Normal vision and hearing reported by the parents.
Correct Answer: A
Rationale: Pallor of nail beds and mucous membranes indicates anemia or poor perfusion, a serious concern in sickle cell disease requiring immediate follow-up.
A 3-year-old child receiving chemotherapy after surgery for a Wilms' tumor has developed neutropenia. The parent is trying to encourage the child to eat by bringing extra foods to the room. Which food would not be appropriate for this child?
- A. Fudge.
- B. French fries.
- C. Fresh strawberries.
- D. A milk shake.
Correct Answer: C
Rationale: Raw fruits carry infection risk.