Nokea
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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Hemangiomas are the most common benign tumors of infancy, occurring more in full-term infants. Of the following, the most common risk factor of development of hemangioma is
- A. male infant
- B. female infant
- C. infant of diabetic mother
- D. infant delivered by cesarean section
Correct Answer: B
Rationale: Female infants are at higher risk for developing hemangiomas.
A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart sound does the nurse expect to assess?
- A. Palpitations
- B. Wheeze
- C. Murmur
- D. Physiologic splitting
Correct Answer: C
Rationale: A ventricular septal defect (VSD) is a congenital heart defect characterized by a hole in the septum that separates the heart's two lower chambers (ventricles). When assessing a child with an unrepaired VSD, the nurse would expect to hear a murmur. The murmur is typically described as a harsh, holosystolic (pansystolic) murmur, best heard at the left lower sternal border. This murmur occurs due to the turbulent blood flow across the defect during systole. It is important for the nurse to recognize this characteristic murmur associated with a VSD to facilitate appropriate management and follow-up care for the child.
A patient with abnormal sodium losses is receiving a house diet. To provide 1,600mg sodium daily, the nurse could supplement the patient's diet with:
- A. One beef cube and 8oz of tomato juice
- B. One beef cube and 16oz of tomato juice
- C. Four beef cubes and 8oz of tomato juice
- D. One beef cube and 12oz tomato juice
Correct Answer: D
Rationale: One beef cube typically contains about 800mg of sodium, and 8oz of tomato juice contains approximately 480mg of sodium. Therefore, to provide a total of 1,600mg of sodium daily, the nurse could supplement the patient's diet with one beef cube (800mg sodium) and 12oz of tomato juice (720mg sodium). This combination would effectively provide the required 1,600mg of sodium per day for the patient with abnormal sodium losses.
A patient is being given penicillin via IV piggyback and develops an anaphylactic reaction. Which of the following should be the nurse's first action?
- A. Call the doctor
- B. Maintain the antibiotic
- C. Call for help
- D. Turn off the antibiotic
Correct Answer: D
Rationale: In the scenario of a patient developing an anaphylactic reaction to penicillin via IV piggyback, the nurse's first action should be to discontinue the administration of the antibiotic to prevent further exposure and potential worsening of the reaction. Turning off the antibiotic is critical as it stops the source of the allergic reaction. This step takes precedence over any other actions including calling the doctor, maintaining the antibiotic, or calling for help, as stopping the infusion is the most immediate and important action to take in managing an anaphylactic reaction. Once the antibiotic has been turned off, the nurse can then proceed with providing appropriate emergency treatments and notifying the healthcare team for further management.
The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse's first action be?
- A. Notify practitioner.
- B. Stop the transfusion.
- C. Administer calcium gluconate.
- D. Monitor vital signs electronically.
Correct Answer: B
Rationale: Slight respiratory distress and tachycardia in a newborn during an exchange transfusion may indicate a possible transfusion reaction or overload. The first action the nurse should take is to stop the transfusion to prevent any further complications and assess the newborn's condition. After stopping the transfusion, the nurse can then take appropriate steps such as notifying the practitioner, administering medications, or providing supportive care as needed.