When caring for a child that has undergone a tonsillectomy, the nurse should do which of the following?

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Question 1 of 5

When caring for a child that has undergone a tonsillectomy, the nurse should do which of the following?

Correct Answer: A

Rationale: When caring for a child that has undergone a tonsillectomy, the nurse should observe for continuous swallowing. Continuous swallowing may indicate bleeding, and it is important to monitor for this postoperatively as it can be a sign of hemorrhage, which is a potential complication following a tonsillectomy. Encouraging the child to take sips of clear fluids can help in assessing if there is bleeding. Observing for any signs of bleeding, such as frequent swallowing, along with monitoring vital signs and overall assessment, is crucial during the initial postoperative period.

Question 2 of 5

The nurse is assessing a 3-month-old during a well-baby visit. Which of the following findings would warrant the nurse to recommend that the baby have an ultrasound for a possible diagnosis of developmental dysplasia of the hip (DDH)?

Correct Answer: B

Rationale: Developmental dysplasia of the hip (DDH) is a condition where the hip joint does not develop normally. It is important to detect DDH early in infants as it can lead to long-term hip problems. One of the key physical exam findings that may suggest DDH is unequal knee heights when the infant's legs are flexed. This is known as the Galeazzi sign, and it can indicate hip dysplasia or dislocation. Therefore, if a nurse observes this finding during an assessment of a 3-month-old infant, it would warrant recommending an ultrasound to further evaluate for possible DDH. Bilateral plantar flexion, bilateral polydactyly, and a positive Babinski test are not typically associated with DDH.

Question 3 of 5

When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?

Correct Answer: A

Rationale: When assessing a female adolescent for scoliosis, the nurse should ask the client to bend forward at the waist with arms hanging freely. This Adams forward bend test allows the nurse to evaluate the spine for any asymmetry, curvature, or rib hump that may indicate scoliosis. By observing the alignment of the spine while the client is in a forward bent position, the nurse can gather important information to determine if further evaluation or referral to a healthcare provider is necessary.

Question 4 of 5

which of the following is a characteristic in a child with acute lymphocytic leukemia?

Correct Answer: D

Rationale: Children with acute lymphocytic leukemia commonly present with a combination of symptoms which can include fatigability, persistent fever of unknown cause, and a tendency to bruise easily. Fatigue is a common complaint in children with leukemia due to anemia caused by decreased production of healthy red blood cells. Persistent fevers can be a sign of infection, anemia, or other complications related to leukemia. Additionally, children with leukemia may have a low platelet count, leading to easy bruising or bleeding tendencies. Therefore, all of the characteristics mentioned in the options are correct for a child with acute lymphocytic leukemia.

Question 5 of 5

the frontal fontanell is protruding when a child suffering from:

Correct Answer: D

Rationale: The protrusion of the frontal fontanelle in a child can be a concerning sign and can be seen in various conditions such as meningitis, hydrocephalus, and subdural hematoma. In meningitis, the inflammation of the meninges can lead to increased intracranial pressure, which may cause the fontanelle to bulge. Hydrocephalus, which is the buildup of fluid in the brain, can also result in the fontanelle being more pronounced. Additionally, a subdural hematoma, which is a collection of blood between the brain and its outermost covering, can lead to pressure on the brain and consequent fontanelle protrusion. Therefore, all the provided choices (A, B, C) are correct as they can lead to the protrusion of the frontal fontanelle in a child.

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