Which diversional activity suggested by the nurse is most appropriate for the child during the acute phase of rheumatic fever?
- A. Playing with action figures
- B. Playing video games
- C. Reading an adventure story
- D. Pounding wooden pegs with a mallet
Correct Answer: C
Rationale: During the acute phase of rheumatic fever, the child is on bed rest to reduce cardiac workload. Reading an adventure story is a quiet, non-physically demanding activity appropriate for a 7-year-old, promoting rest while keeping the child engaged.
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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 the delivery of fetus,placenta should be removed by:
- A. Fundal pressure.
- B. D & C.
- C. Brandt-Andrews method.
- D. Manual removal.
- E. C-section.
Correct Answer: C
Rationale: The Brandt-Andrews method using controlled cord traction is the standard technique for delivering the placenta in the third stage of labor. Other methods are used only in complications.
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.
Breech extraction is only indicated in:
- A. Retained second twin.
- B. Footling breech.
- C. Extended breech.
- D. Flexed breech.
- E. Breech in first twin.
Correct Answer: A
Rationale: Breech extraction is indicated for a retained second twin to expedite delivery and prevent complications. Other breech presentations typically require cesarean section or external cephalic version.
The nurse assesses that the full-term newborn’s head has molding. Considering this finding,which information should the nurse expect to see on the mother’s labor and delivery documentation?
- A. Vaginal breech birth
- B. Planned cesarean birth,no labor
- C. Was in labor for 16 hours
- D. Precipitous delivery after a 30-minute labor
Correct Answer: C
Rationale: A 16-hour labor causes molding due to prolonged pressure of the fetal head against the cervix. Breech births cesarean sections or short labors produce minimal or no molding.
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