Nokea
Which of the following assessment findings would alert the nurse that the child may be exhibiting early signs of sepsis?
- A. Increased level of pain
- B. Disorientation
- C. Decreased urine output
- D. Jitteriness
Correct Answer: B
Rationale: Disorientation can indicate early sepsis in burn patients, reflecting systemic infection affecting the central nervous system. Other signs like fever or tachycardia may also occur, but disorientation is a critical early warning.
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The nurse is preparing the parents of a full-term,24-hour-old male newborn for discharge with their infant. Which are the expected discharge criteria that should be met before the infant leaves the hospital? Select all that apply.
- A. Infant vital signs have been normal for the last 12 hours.
- B. The infant has passed at least three meconium stools.
- C. The infant has gained weight at the minimum 100 grams.
- D. The circumcision has had no bleeding for the last 2 hours.
- E. The infant has had six diaper changes in the last 24 hours.
- F. The infant has completed 2 successful consecutive feedings.
Correct Answer: A,D,F
Rationale: Discharge criteria include stable vital signs for 12 hours no circumcision bleeding for 2 hours and two successful feedings. One meconium stool is sufficient weight gain isn’t required and diaper changes aren’t specified.
Which finding by the nurse strongly indicates that a child is experiencing hypokalemia?
- A. Full, bounding pulses
- B. Muscle weakness
- C. Elevated blood pressure
- D. Hyperactive bowel sounds
Correct Answer: B
Rationale: Hypokalemia causes muscle weakness due to impaired muscle contraction, a key manifestation resulting from low potassium levels affecting neuromuscular function.
18 years old P1 presents in outpatient department ten days after delivery with tender hot painful swelling in right breast. She also complains of fever with rigors. What will be the most likely management:
- A. Antibiotics.
- B. Analgesics.
- C. Incision & drainage.
- D. Conservative management.
- E. Lactation inhibition.
Correct Answer: C
Rationale: The symptoms suggest a breast abscess which requires incision and drainage for effective treatment especially with systemic symptoms like fever. Antibiotics alone are insufficient for an abscess and other options are inappropriate.
Of the following methods,the safest,most precise and simplest for placental localization is:
- A. Auscultation.
- B. Ultrasonography.
- C. Radioisotope study.
- D. Abdominal palpation.
- E. Soft tissue radiography.
Correct Answer: B
Rationale: Ultrasonography is the safest most precise and simplest method for placental localization offering real-time imaging without radiation. Other methods are less accurate or involve risks.
Maximum normal time for second stage of labour in primigravida without anaesthesia is about:
- A. 20 minutes.
- B. 60 minutes.
- C. 120 minutes.
- D. 240 minutes.
- E. There is no normal maximum.
Correct Answer: C
Rationale: The second stage in primigravida without anesthesia is typically up to 2 hours (120 minutes). Beyond this intervention is considered due to risks of maternal or fetal distress.