Nokea
Which nursing action is most appropriate at this time?
- A. Recognize that the fluid is cerebrospinal fluid (CSF) and remove the dressing, observing for the source of the leakage.
- B. Recognize that the fluid is CSF and call the chaplain because death of the child is imminent.
- C. Recognize that the fluid is CSF and notify the operating room because additional surgery will be necessary.
- D. Recognize that the fluid is CSF and reinforce the dressing until the physician can change it.
Correct Answer: D
Rationale: Clear drainage on a head dressing post-craniotomy is likely CSF, indicating a leak. Reinforcing the dressing prevents infection and maintains a sterile barrier until the physician assesses the leak.
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Which nursing instruction is correct for the parents of a child who has a vitamin D deficiency?
- A. Give the child cod liver oil daily.
- B. Give the child orange juice daily.
- C. Apply sunblock to the child before sun exposure.
- D. Keep the child indoors during daylight hours.
Correct Answer: A
Rationale: Cod liver oil is a rich source of vitamin D, essential for correcting vitamin D deficiency and supporting bone health.
The nurse is caring for a preterm infant with respiratory distress syndrome (RDS). Which intervention should the nurse implement to maximize the infant’s respiratory status?
- A. Check blood glucose levels every 4 hours.
- B. Cool and humidify all inspired gases.
- C. Weigh the infant every other day.
- D. Place the infant in a prone position.
Correct Answer: D
Rationale: The prone position improves oxygenation in collapsed alveoli for RDS infants with cardiorespiratory monitoring. Glucose checks cold gases and infrequent weighing don’t aid respiration.
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.
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.
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.