Question

16. A nurse is caring for a 10-month-old child who was brought to the emergency department by his parents following a head injury. Which of the following actions should the nurse take first?
a. Inspect for fluid leaking from the ears
b. Assess respiratory status
c. Check pupil reactions
d. Examine the scalp for lacerations

17. A nurse is providing teaching to the parents of an infant who is to undergo pilocarpine iontophoresis testing for cystic fibrosis. Which of the following statements should the nurse include in the teaching?
a. “A nurse will insert an IV prior to the test”
b. “Your baby will need to fast for 8 hours prior to the test”
c. “The test will measure the amount of chloride in your baby’s sweat”
d. “We will measure the amount of protein in your baby’s urine over a 24 hour period”

18. A nurse is planning care for 6-month-old infant who has bacterial meningitis. Which of the following interventions should the nurse include in the plan of care?
a. Pad the side rails of the crib
b. Provide frequent range of motion to the neck and shoulders
c. Keep the television on in the room to provide background noise
d. Place the infant in a semiprivate room

19. A nurse is preparing to administer immunizations to a 3-month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?
a. Provide a pacifier coated with an oral sucrose solution prior to the injections
b. use a 20-gauge needle for the injections
c. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections
d. Inject the immunizations into the deltoid muscle

21. A nurse is providing teaching to the parents of a 2-month-old infant who has developmental dysplasia of the hip and has a prescription for a Pavlik harness. Which of the following statements by the parents indicates an understanding of the teaching?
a. “We will apply lotion to the skin under the straps”
b. “We should adjust the straps daily”
c. “We will place the diaper under the straps”
d. “We should expect our baby to wear this harness for 2 weeks”

Answer 1

Ans.

(16)

B. Assess respiratory status.

Assessment of the head injury patient should include airway, cervical spine protection, breathing, circulation, and haemorrhage control followed by the GCS. The GCS score should be used in the assessment of all patients with head injury by trained healthcare providers.

(17)

C. “The test will measure the amount of chloride in your baby’s sweat”

(18)

d. Place the infant in a semiprivate room

Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

(19)

D. Inject the immunizations into the deltoid muscle

(21)

D. We should expect our baby to wear this harness for 2 weeks”