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Why place an undershirt between the skin and the Pavlik harness?
- A. To keep the skin moist
- B. To prevent infection caused by pins of the Pavlik harness
- C. To prevent skin abrasions and irritation by the harness
- D. To keep the skin clean
Correct Answer: C
Rationale: Placing an undershirt between the skin and the Pavlik harness is done to prevent skin abrasions and irritation caused by the harness rubbing directly against the skin. The undershirt acts as a protective layer, reducing the likelihood of skin sensitivity or damage due to the continuous contact with the harness. This is particularly important for infants or young children who may have delicate skin that is more prone to irritation. By using an undershirt, caregivers can help ensure greater comfort for the child while wearing the Pavlik harness and reduce the risk of any skin-related complications.
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Failure to thrive (FTT) is a descriptive term given to malnourished infants and young children who fail to meet expected standards of growth. Of the following, the growth parameter that is usually not affected by malnutrition is
- A. weight
- B. height
- C. weight for height ratio
- D. head circumference
Correct Answer: D
Rationale: Head circumference is less likely to be affected by short-term malnutrition because brain growth is prioritized during infancy and early childhood.
A child is diagnosed with Wilms' tumor. During assessment, the nurse in charge expects to detect:
- A. Gross hematuria
- B. Dysuria
- C. Nausea and vomiting
- D. An abdominal mass
Correct Answer: D
Rationale: In a child with Wilms' tumor, the nurse would expect to detect an abdominal mass upon assessment. Wilms' tumor, also known as nephroblastoma, is a type of kidney cancer that commonly presents as a firm, non-tender abdominal mass. This mass may be felt upon palpation of the abdomen. Gross hematuria (A) is not a typical finding associated with Wilms' tumor. Dysuria (B) is the term used to describe painful or difficult urination and is not a characteristic symptom of Wilms' tumor. Nausea and vomiting (C) are also not commonly associated with Wilms' tumor, unless the tumor is causing obstruction or compression of nearby structures in the abdomen.
The primary critical observation for Apgar scoring is the:
- A. Heart rate
- B. Respiratory rate
- C. Presence of meconium
- D. Evaluation of the Moro reflex
Correct Answer: A
Rationale: The primary critical observation for Apgar scoring is the heart rate. This is because the heart rate is vital for life and immediate assessment of the infant's heart rate provides crucial information about the baby's overall well-being and response to the birthing process. The Apgar score assesses five components: heart rate, respiratory effort, muscle tone, reflex irritability, and skin color. Among these components, the heart rate is considered the most critical because it directly reflects the infant's cardiovascular status and their ability to maintain adequate perfusion of vital organs. Therefore, for quick assessment and immediate intervention, the heart rate is prioritized as the primary observation in Apgar scoring.
An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action?
- A. Ask her why she wants to know.
- B. Determine why she is so anxious.
- C. Explain in simple terms how it works.
- D. Tell her she will see how it works as it is used.
Correct Answer: C
Rationale: The most appropriate nursing action when an 8-year-old girl asks how the blood pressure apparatus works is to explain in simple terms how it works. Children are curious by nature and providing a simple explanation in a language they can understand helps satisfy their curiosity and also promotes their understanding. By explaining how the blood pressure apparatus works, the nurse can educate the child about a common medical device and reduce any anxiety or fear the child may have about it. This approach encourages the child to feel more comfortable and engaged in their healthcare experience.
Why must clients who will undergo diagnostic skin test avoid taking antihistamine or cold preparations for at least 48-72 hrs before testing?
- A. Antihistamines may increase the potential for excessive bleeding
- B. Antihistamines may aggravate the allergic reaction
- C. Antihistamines may increase the potential for false negative results
- D. Antihistamines may cause wheezing
Correct Answer: C
Rationale: Antihistamines are medications commonly used to relieve symptoms of allergies, including itching, sneezing, and hives. When a client undergoing a diagnostic skin test for allergies takes antihistamines, it can suppress the body's allergic response, leading to false negative results. This means that the test may not accurately identify all the substances to which the client is allergic, potentially leading to a misdiagnosis. To ensure the accuracy of the skin test, clients are advised to avoid taking antihistamines or cold preparations for at least 48-72 hours before the testing to allow their body to exhibit the appropriate allergic response.