Nokea
While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as which of the following?
- A. Spina bifida cystica.
- B. Spina bifida occulta.
- C. Meningocele.
- D. Myelomeningocele.
Correct Answer: B
Rationale: An indentation with a tuft of hair suggests spina bifida occulta, a mild defect without protrusion of spinal contents.
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A nursing assistant is taking care of a child in the arm restraint shown below. To provide care for this child, what should the assistant do?
- A. Unpin the restraint and perform range-ofmotion exercises.
- B. Unwrap the restraint and bathe the arm using warm water
- C. Leave the restraint in its current position.
- D. Remove one tape at a time while bathing the child’s arm.
Correct Answer: C
Rationale: The restraint should remain in position. Removing the restraint or untaping the restraint will risk dislodging the I.V.
The mother calls the nurse to report that her toddler has just been burned on the arm. The nurse should advise the mother to first:
- A. Pack the arm in ice, then take the child to the closest emergency department.
- B. Rub the burned area with an antibacterial ointment, then call the doctor.
- C. Run cool water over the burned area, then wrap it in a clean cloth.
- D. Call the child's health care provider immediately, then wrap the arm in a clean cloth.
Correct Answer: C
Rationale: Running cool water over the burn reduces tissue damage and pain, followed by wrapping in a clean cloth to protect the area before seeking medical care.
The nurse notes that the client's continuous electrocardiogram (ECG) complexes are very small and hard to evaluate. Which setting on the ECG monitor console should the nurse check?
- A. Power button
- B. Low rate alarm
- C. High rate alarm
- D. Amplitude or 'gain'
Correct Answer: D
Rationale: The amplitude, commonly called 'gain,' regulates the size of the complex and can be adjusted up and down to some degree. The power button turns the machine on and off. The low and high alarm settings indicate the heart rate limits beyond which an alarm will sound.
Neuroleptic malignant syndrome is suspected in a client who is prescribed an atypical antipsychotic medication. Which medication should the nurse prepare in anticipation of being prescribed to treat this adverse effect related to the use of this medication?
- A. Bromocriptine
- B. Protamine sulfate
- C. Enalapril maleate
- D. Phytonadione (vitamin K)
Correct Answer: A
Rationale: Bromocriptine is a dopamine pathway medication used in the treatment of neuroleptic malignant syndrome. Protamine sulfate is the antidote for heparin overdose. Vitamin K is the antidote for warfarin overdose. Enalapril maleate is an angiotensin-converting enzyme inhibitor and an antihypertensive that is used in the treatment of hypertension.
When teaching a group of parents about the potential for febrile seizures in children, which of the following facts should the nurse include?
- A. The exact cause is known.
- B. The seizures occur as the fever rises.
- C. Children older than age 3 are most at risk.
- D. These seizures commonly occur after immunization administration.
Correct Answer: B
Rationale: Febrile seizures typically occur as the fever rises rapidly in young children (usually under age 5), not specifically after immunizations or in older children.