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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Which nursing action is most appropriate when caring for a child experiencing a sickle cell crisis?
- A. Apply heat to the affected joints.
- B. Administer oxygen as ordered.
- C. Encourage vigorous physical activity.
- D. Provide a high-sodium diet.
Correct Answer: B
Rationale: Administering oxygen as ordered improves oxygenation, critical during a sickle cell crisis to counteract hypoxia caused by vaso-occlusion and reduced oxygen-carrying capacity.
After assisting in the delivery of a full-term infant with anencephaly,the parents ask the nurse to explain treatments that might be available for their infant. Which statement should be the basis for the nurse’s response?
- A. Immediate surgery is necessary to repair the congenital defect.
- B. Anencephaly is incompatible with life; only palliative care should be provided.
- C. A shunting procedure will be necessary initially to relieve intracranial pressure.
- D. Antibiotics are needed initially before any treatment is started.
Correct Answer: B
Rationale: Anencephaly lacking cerebral hemispheres and skull is incompatible with life warranting only palliative care. Surgery shunting or antibiotics cannot correct it.
Crowning is best defined as:
- A. When the greatest diameter of fetal head comes through vulva.
- B. When presenting part reaches the pelvic floor.
- C. When the perineum bulges in front of fetal head.
- D. When fetal head is visible at vulva.
- E. When head is delivered.
Correct Answer: C
Rationale: Crowning occurs when the perineum bulges due to the fetal head’s largest diameter stretching the vaginal opening just before delivery. Other definitions describe different stages.
An infant had four wet diapers during the 8-hour shift. The weight of a dry diaper is 15 g. The four wet diapers weighed 30 g, 24 g, 21 g, and 25 g. What amount in milliliters should the nurse record for the total 8-hour urine? _______ mL (Record your answer as a whole number.)
Correct Answer: 40
Rationale: Subtract dry diaper weight (15 g): 30–15=15 g 24–15=9 g 21–15=6 g 25–15=10 g. Total: 15+9+6+10=40 g equaling 40 mL urine output.
The nurse is caring for the full-term newborn male who is 24 hours old and was circumcised with a Gomco clamp 30 minutes ago. Which interventions should the nurse plan for care of the newborn’s circumcision? Select all that apply.
- A. Monitor the newborn’s penis hourly for 4 to 6 hours.
- B. Observe for and document the first voiding after circumcision.
- C. Use prepackaged commercial diaper wipes for perineal cleansing.
- D. Apply petroleum ointment around the penis after each diaper change.
- E. Apply tightly a size-smaller diaper to provide hemostasis.
Correct Answer: A,B,D
Rationale: Monitor the penis for swelling/bleeding document first void to rule out obstruction and apply petroleum ointment to prevent bleeding. Commercial wipes may irritate and tight diapers cause pain.