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Which site is preferred for giving an IM injection to a newborn?
- A. Ventrogluteal
- B. Vastus lateralis
- C. Rectus femoris
- D. Dorsogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. The vastus lateralis muscle is preferred for IM injections in newborns due to its large muscle mass, minimal risk of injury to major blood vessels and nerves, and easy accessibility. It is also recommended by healthcare guidelines for infants. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of damaging nerves and blood vessels. The rectus femoris muscle is not typically used for IM injections in newborns as it is less accessible and has a higher risk of injury.
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A nurse is initiating a plan of care for a toddler who is hospitalized. Which of the following instructions is important to communicate to the nursing assistant?
- A. Have the toddler dress himself.
- B. Offer the toddler finger foods for snacks.
- C. Provide opportunities to share toys with others.
- D. Ask the child simple yes or no questions.
Correct Answer: B
Rationale: The correct answer is B: Offer the toddler finger foods for snacks. This instruction is important to communicate to the nursing assistant because toddlers are at risk for choking on certain foods due to their developing chewing and swallowing abilities. Finger foods are safer for toddlers to eat as they are easier to manage and reduce the risk of choking.
Other choices are incorrect because:
A: Having the toddler dress himself may not be appropriate as toddlers may need assistance and supervision due to their limited motor skills.
C: Providing opportunities to share toys with others is important for social development but is not as critical as ensuring the toddler's safety during meal times.
D: Asking the child simple yes or no questions is a good communication strategy but not as essential for the toddler's safety during snack times.
A nurse is monitoring a child whose parents are suspected of child neglect. Which of the following is an expected finding of neglect?
- A. Lack of required immunizations
- B. Parental lack of education
- C. Lower socioeconomic group
- D. Faded clothing with large shoes
Correct Answer: A
Rationale: The correct answer is A: Lack of required immunizations. Neglect refers to the failure to provide for a child's basic needs, including healthcare. Lack of immunizations puts the child at risk for preventable diseases, indicating neglect. Parental lack of education (B) or being in a lower socioeconomic group (C) do not directly indicate neglect. Faded clothing with large shoes (D) may suggest financial difficulties but does not necessarily indicate neglect.
A client is admitted to the hospital for induction of labor. Which are the main indications for labor induction?
- A. Placenta previa and twins
- B. Pregnancy-induced hypertension and postterm fetus
- C. Breech position and prematurity
- D. Cephalopelvic disproportion and fetal distress
Correct Answer: B
Rationale: The correct answer is B: Pregnancy-induced hypertension and postterm fetus. Labor induction is commonly indicated in cases of pregnancy-induced hypertension to prevent complications such as preeclampsia. Postterm fetus is another common indication to prevent risks associated with a prolonged pregnancy, such as stillbirth. Placenta previa, twins, breech position, prematurity, cephalopelvic disproportion, and fetal distress are not typically primary indications for labor induction. Placenta previa may require a cesarean section, twins may be delivered vaginally or by C-section, breech position may require external cephalic version or C-section, prematurity may necessitate medical management, cephalopelvic disproportion may require a C-section, and fetal distress may necessitate immediate delivery but not necessarily labor induction.
A nurse is caring for a child with measles.
- A. "Provide diversional activities such as video games."'
- B. "Maintain isolation for 48 hr after the rash resolves."'
- C. "Keep the child warm with adequate undergarments and bedding."'
- D. "Administer vitamin A supplements as prescribed."'
Correct Answer: D
Rationale: The correct answer is D because administering vitamin A supplements is a standard treatment for measles to reduce complications and improve recovery. Vitamin A deficiency is common in children with measles, and supplementation can help boost the immune system and reduce the severity of the illness. Providing diversional activities (choice A) may be suitable but does not directly address the medical needs of the child. Maintaining isolation (choice B) is important but typically lasts until 4 days after rash onset, not just 48 hours after rash resolution. Keeping the child warm (choice C) is a general comfort measure and may not directly impact measles treatment.
A nurse is caring for a 4-year-old child who is prescribed an intravenous medication preoperatively. Which of the following therapeutic play techniques is most appropriate when reinforcing the teaching for this procedure?
- A. Role play with another nurse the technique of IV placement and how the medication is infused.
- B. Read a story that explains the basics of how IVs are placed.
- C. Watch a movie narrated by nurses and children about IV placement.
- D. Explain the basic procedure and give the child IV supplies to play with minus the needle.
Correct Answer: D
Rationale: The correct answer is D because explaining the basic procedure and providing the child with IV supplies to play with (minus the needle) allows the child to familiarize themselves with the equipment in a non-threatening manner. This technique helps reduce anxiety and fear associated with the procedure. Role-playing may not be suitable for all children as it can be too abstract for a 4-year-old. Reading a story may not provide the hands-on experience needed to understand the procedure. Watching a movie may not be interactive enough for the child to actively engage in the learning process. Providing IV supplies for play is the most appropriate therapeutic play technique for a 4-year-old to prepare them for the IV placement procedure.