Nokea
Which client symptoms documented by the nurse best indicate that the child is having a hypoglycemic reaction? Select all that apply.
- A. The child complains of being thirsty.
- B. The child's breathing is labored and prolonged.
- C. The child is more hungry than usual.
- D. The child complains of feeling shaky.
- E. The child reports feeling light-headed.
- F. The child states his or her heart is racing.
Correct Answer: D,E,F
Rationale: Hypoglycemia causes shakiness, light-headedness, and tachycardia due to low blood glucose triggering the sympathetic nervous system. Thirst and hunger are less specific, and labored breathing is unrelated.
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A healthy postpartum mother who is breastfeeding her term infant tells the nurse that she has noticed that her roommate is feeding iron-enriched formula to her newborn. The mother asks if she should be giving her baby supplemental iron. Which response by the nurse is correct?
- A. “Your breast milk provides all the iron your baby needs.”
- B. “You,not your baby will need an iron supplement daily.”
- C. “Your pediatrician will prescribe iron drops for your baby.”
- D. “You should feed your baby iron-fortified formula once daily.”
Correct Answer: A
Rationale: Breast milk provides sufficient highly bioavailable iron for term infants making supplementation unnecessary. Maternal iron supplements or formula feeding are not required.
A G2P1 with previous cesarean section due to obstructed labour comes for first antenatal visit at 34 weeks of gestation. She is seeking advice for home delivery this time. What will be the most dangerous complication in her case if we allow her to deliver at home by untrained birth attendent:
- A. Prolonged latent phase.
- B. Arrest in second stage of labour.
- C. Delayed progress in active phase of labour.
- D. Rupture uterus.
- E. Placental retention.
Correct Answer: D
Rationale: Uterine rupture is a life-threatening complication in women with a previous cesarean section especially during labor managed by untrained attendants due to the risk of scar dehiscence. Other complications are less immediately dangerous.
Which assessment finding may indicate a serious neurovascular problem that should be reported immediately to the charge nurse or physician?
- A. The toes of the left foot are warmer than the toes of the right foot.
- B. The toes of both feet are cool to the touch.
- C. The child is unable to wiggle the toes of the right foot.
- D. The capillary refill in the toes of the right foot is 2 seconds.
Correct Answer: C
Rationale: Inability to wiggle toes suggests neurovascular compromise, such as nerve or vascular injury, requiring immediate reporting to prevent permanent damage.
The nurse should plan to keep which equipment or supplies in the burned child's room in case an emergency arises?
- A. An extra supply of sterile dressing
- B. An endotracheal tube and oxygen supply
- C. Equipment to administer pain medication
- D. Additional bags of I.V. fluid
Correct Answer: B
Rationale: Burn patients are at risk for airway compromise due to inhalation injury or edema. Keeping an endotracheal tube and oxygen supply available is critical for emergency airway management.
When teaching an adolescent male client about testicular self-examination, which instruction should the nurse include?
- A. Have examination after a warm bath or shower.
- B. Report any difference in the size of your testicles to the physician.
- C. Malignant lumps are usually located on the front side of the testicles.
- D. Both testicles should be examined simultaneously to detect differences.
Correct Answer: A
Rationale: Performing testicular self-examination after a warm bath or shower relaxes the scrotum, making it easier to detect abnormalities, a key instruction for effective screening.