Nokea
Which of the following would indicate that an infant with a tracheoesophageal fistula (TEF) needs suctioning?
- A. Brassy cough.
- B. Substernal retractions.
- C. Decreased activity level.
- D. Increased respiratory rate.
Correct Answer: B
Rationale: Substernal retractions indicate respiratory distress, often due to mucus accumulation in TEF, necessitating suctioning.
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When explaining to parents how to reduce the risk of Sudden Infant Death Syndrome (SIDS) the nurse should teach about which of the following measures? Select all that apply.
- A. Maintain a smoke-free environment.
- B. Use a wedge for side-lying positions.
- C. Breast-feed the baby.
- D. Place the baby on his back to sleep.
- E. Use bumper pads over
- F. Have the baby sleep in the parent's bed.
Correct Answer: A,C,D
Rationale: Maintaining a smoke-free environment, breastfeeding, and placing the baby on his back to sleep are evidence-based measures to reduce SIDS risk. Side-lying positions, bumper pads, and bed-sharing increase SIDS risk and should be avoided.
While performing daily peritoneal dialysis and catheter exit site care with the mother of a child with chronic renal failure, which of the following would be an important step to emphasize to the mother?
- A. Applying an occlusive dressing after cleaning the site.
- B. Changing the dressing when the peritoneal space is dry.
- C. Examining the site for signs of infection while cleaning the area.
- D. Pulling on the catheter to hold taut while cleaning the skin.
Correct Answer: C
Rationale: Checking for signs of infection is crucial.
A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see figure). The nurse should do which of the following?
- A. Reposition the infant to the left side.
- B. Ask the parents to put the infant back in his crib.
- C. Remind the parents that the infant cannot use a pacifier now.
- D. Tell the parents they have positioned their infant correctly.
Correct Answer: D
Rationale: An infant seat is appropriate for a 6-month-old post-pyloromyotomy, supporting recovery and comfort.
A child with celiac disease is at risk for which complication if the diet is not followed?
- A. Renal failure.
- B. Intestinal lymphoma.
- C. Pulmonary fibrosis.
- D. Cardiomyopathy.
Correct Answer: B
Rationale: Untreated celiac disease increases the risk of intestinal lymphoma due to chronic inflammation. Renal, pulmonary, or cardiac complications are not directly associated.
Which of the following assessment findings should alert the nurse to suspect appendicitis in a male adolescent complaining of severe abdominal pain?
- A. Abdomen appears slightly rounded.
- B. Bowel sounds are heard twice in 2 minutes.
- C. All four abdominal quadrants reveal tympany.
- D. The client demonstrates a cremasteric reflex.
Correct Answer: B
Rationale: Decreased bowel sounds suggest appendicitis due to peritoneal irritation.