Which is most important in the immediate care of the newborn?

Correct Answer: A

Rationale: Maintaining a patent airway is the most critical aspect in the immediate care of a newborn. An open airway is essential for the newborn to breathe effectively and receive adequate oxygen. Any obstruction in the airway can lead to respiratory distress and compromise the baby's oxygenation. Therefore, ensuring the airway is clear and the newborn can breathe properly is the top priority in providing immediate care. While other choices are important aspects of newborn care, ensuring a patent airway takes precedence in order to support the newborn's respiratory function and overall well-being.

Correct Answer: C

Rationale: Toxic shock syndrome is characterized by several clinical manifestations, including a diffuse erythematous macular rash. The rash typically appears early in the course of the illness and may be followed by desquamation (peeling of the skin). Other common symptoms of toxic shock syndrome include fever, hypotension, multi-organ dysfunction, headache, myalgia, and gastrointestinal symptoms. Severe hypertension and subnormal temperature are not typically associated with toxic shock syndrome. Papular rash over extremities is not a classic manifestation of toxic shock syndrome.

Correct Answer: B

Rationale: When preparing a school-age child and the family for heart surgery, it is essential to provide honest and age-appropriate information to help the child feel more comfortable and reduce anxiety. Letting the child hear the sounds of an ECG monitor is beneficial as it allows them to become familiar with medical equipment and procedures, making them less intimidated by the unfamiliar sounds they may encounter during and after surgery. Familiarizing the child with the sounds can also help alleviate fears and promote understanding of what is happening during the procedure. It is important to maintain open communication, address concerns, and prepare the child and family for what to expect before, during, and after surgery.

Correct Answer: D

Rationale: The nurse should notify the physician stat in this situation. The presence of blood-tinged urine and painful bladder spasms in a patient with a three-way Foley catheter and continuous bladder irrigation post TURP could indicate a potential complication such as hemorrhage or clot retention. It is crucial to ensure prompt medical evaluation and intervention to address these issues effectively. Waiting or administering pain medication without further assessment could delay necessary treatment and lead to worsening of the patient's condition. Therefore, notifying the physician immediately is the most appropriate action in this scenario.

Correct Answer: C

Rationale: For a preschool child, the appropriate explanation about cardiac catheterization would be that the test is short, usually taking less than 1 hour. This explanation is suitable for a preschool child because it provides a simple and clear understanding of what to expect during the procedure. Preschool-aged children have limited attention spans and may become anxious about medical procedures, so providing a concise and reassuring explanation can help alleviate their fears. Additionally, knowing that the test will not take a long time can help the child feel more at ease about the procedure.