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Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea?
- A. Moist mucous membranes.
- B. Passage of a soft, formed stool.
- C. Absence of diarrhea for a 4-hour period.
- D. Ability to tolerate intravenous fluids well.
Correct Answer: A
Rationale: Moist mucous membranes indicate adequate hydration, the goal of treatment.
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While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which of the following would be most important for the nurse to do?
- A. Check the diaper for recent urination.
- B. Give the infant a pacifier.
- C. Ensure that the room is kept warm.
- D. Tap lightly on the left inguinal ring.
Correct Answer: C
Rationale: Ensuring the room is warm helps relax the cremaster muscle, facilitating examination.
Preoperatively, the nurse develops a plan to prepare a 7-month-old infant psychologically for a scheduled herniorrhaphy the next day. Which of the following should the nurse expect to implement to accomplish this goal?
- A. Explaining the preoperative and postoperative procedures to the mother.
- B. Having the mother stay with the infant.
- C. Making sure the infant's favorite toy is available.
- D. Allowing the infant to play with surgical equipment.
Correct Answer: B
Rationale: The mother's presence provides comfort and reduces anxiety for a 7-month-old.
When the infant returns to the unit after imperforate anus repair, the nurse should place the infant in which of the following positions?
- A. On the abdomen, with legs pulled up under the body.
- B. On the back, with legs extended straight out.
- C. Lying on the side with the hips elevated.
- D. Lying on the back in a position of comfort.
Correct Answer: C
Rationale: Lying on the side with hips elevated minimizes pressure on the surgical site and promotes healing.
A mother has heard that several children have been diagnosed with mononucleosis. She asks the nurse what ascendancy what precautions should be taken to prevent this from occurring in her child. The nurse should instruct the mother to:
- A. Take no particular precautionary measures.
- B. Sterilize the child's eating utensils before they are reused.
- C. Wash the child's linens separately in hot, soapy water.
- D. Wear masks when providing direct personal care.
Correct Answer: A
Rationale: Mononucleosis spreads through saliva, but routine hygiene is sufficient; no special precautions are needed.
Because of the risks associated with administration of factor VIII concentrate, the nurse should teach the child's family to recognize and report which of the following?
- A. Yellowing of the skin.
- B. Constipation.
- C. Abdominal distention.
- D. Puffiness around the eyes.
Correct Answer: A
Rationale: Yellowing of the skin (jaundice) may indicate hepatitis, a risk with factor VIII. Other symptoms are less directly related to factor risks.