Nokea
Which muscle is contraindicated for the administration of immunizations in infants and young children?
- A. Deltoid
- B. Dorsogluteal
- C. Ventrogluteal
- D. Anterolateral thigh
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which is described as an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?
- A. Cyst
- B. Papule
- C. Pustule
- D. Vesicle
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the appropriate method for measuring the temperature of a 2-day-old neonate?
- A. Tympanic
- B. Oral
- C. Axillary
- D. Rectal
Correct Answer: C
Rationale: For a 2-day-old neonate, the most suitable method to measure temperature is the axillary method. This approach is considered safe and appropriate for neonates, minimizing the risk of injury. Tympanic temperature measurement may not be as accurate in neonates due to their small ear canals. Oral temperature measurement is not recommended for neonates as they may not be able to hold a thermometer properly in their mouths. Rectal temperature measurement is invasive and carries a higher risk of injury and should be avoided unless absolutely necessary.
What interventions would the nurse implement to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid using alkaline-based soap.
- B. Bathe the infant with sterile water.
- C. Cleanse skin with a gentle alkaline-based soap and water.
- D. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
Correct Answer: B
Rationale: To maintain the skin integrity of a preterm infant born at 30 weeks, the nurse should bathe the infant with sterile water no more than two or three times per week. The eyes, oral and diaper areas, and pressure points should be cleansed daily. It is essential to avoid using alkaline-based soaps as they might destroy the 'acid mantle' of the skin. Additionally, cleansing with mild solutions and rinsing thoroughly with plain water is recommended to prevent skin irritation and maintain skin integrity. Therefore, options A, C, and D are incorrect as they do not align with the best practices for preterm infant skin care.
Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?
- A. S1 and S2
- B. S3 and S4
- C. Murmur
- D. Physiologic splitting
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 3-year-old child, previously potty-trained, becomes a bed-wetter again during a hospital stay. Which explanation should the nurse provide to the parents?
- A. "Your child is no longer potty-trained and will need to be retrained when she goes home."
- B. "The child may have developed a bladder infection in the hospital. I will notify the doctor."
- C. "Preschool children may regress in their behaviors when they are ill in the hospital but should return to normal when they go back home."
- D. "Don't worry about it, she is fine."
Correct Answer: C
Rationale: During a hospital stay, preschool children may exhibit regression in behaviors such as bed-wetting due to stress. It is important for parents to understand that this behavior is a common response to the hospital environment and should resolve once the child is back home. Therefore, the correct explanation for the nurse to provide to the parents is choice C. Choice A is incorrect because it inaccurately states that the child is no longer potty-trained. Choice B is incorrect as it assumes a medical issue without evidence. Choice D is incorrect as it dismisses the parents' concerns without addressing the underlying cause of the behavior.