A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. Which action is most important for the nurse to take?

Apply zinc oxide to perineum with each diaper change.

Auscultate the lungs for respiratory pneumonia.

Change to latex-free gloves when handling infant.

Draw blood to analyze for streptococcal infection.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Apply zinc oxide to perineum with each diaper change: Zinc oxide can help treat diaper rash and protect skin integrity, but it does not address the systemic allergic reaction symptoms such as sneezing, urticaria, or watery eyes.

B. Auscultate the lungs for respiratory pneumonia: Lung assessment is important in children with chronic conditions, but the symptoms described (sneezing, urticaria, watery eyes, and rash) indicate an allergic reaction rather than a respiratory infection.

C. Change to latex-free gloves when handling infant: The symptoms are indicative of a latex allergy, which is common in children with myelomeningocele who have frequent catheterizations and medical device exposure. Switching to latex-free gloves is the most important intervention to prevent further allergic reactions and potential anaphylaxis.

D. Draw blood to analyze for streptococcal infection: Streptococcal infections typically present with fever, sore throat, or systemic illness. The child’s symptoms are consistent with an allergic reaction rather than infection, so immediate lab testing for strep is not the priority.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Situate in knee-chest position: Placing the infant in a knee-chest position increases systemic vascular resistance, which helps reduce right-to-left shunting and improves pulmonary blood flow during a hypercyanotic (“Tet”) spell to improve oxygenation and prevent hypoxic injury.

B. Perform chest physiotherapy: Chest physiotherapy is used to mobilize secretions in respiratory conditions but does not address the acute pathophysiology of a Tet spell. It would not rapidly improve oxygenation in this emergency.

C. Reduce flow rate of intravenous fluid replacement: Reducing IV fluids may decrease venous return but does not relieve the hypoxic crisis caused by right-to-left shunting. This intervention is not indicated during a hypercyanotic episode.

D. Administer prescribed morphine subcutaneously: Morphine can be used to calm the infant and reduce pulmonary resistance in some Tet spell protocols, but positioning the infant in a knee-chest posture is the first, immediate action to improve oxygenation before pharmacologic measures.

A. Wear a supportive bra at all times. B. Take two acetaminophen to relieve the discomfort. C. Use breast cream to help prevent discomfort. D. Put a heating pad on the breasts while they are engorged.

Correct Answer is A

Explanation

Rationale:

A. Wear a supportive bra at all times: Wearing a well-fitting, supportive bra helps relieve pressure on engorged breasts and provides comfort while maintaining proper breast support. It can reduce swelling, prevent tissue damage, and make breastfeeding or pumping more manageable during periods of overfull breasts.

B. Take two acetaminophen to relieve the discomfort: Acetaminophen may help reduce pain, but it does not address the underlying cause of engorgement or prevent worsening discomfort. Medication alone is not sufficient as a primary strategy for managing engorged breasts.

C. Use breast cream to help prevent discomfort: Breast creams are designed to prevent nipple soreness or cracking but do not alleviate discomfort from breast engorgement. This intervention would not directly reduce swelling or pressure in overfull breasts.

D. Put a heating pad on the breasts while they are engorged: Applying heat to engorged breasts can worsen swelling by increasing blood flow and may intensify discomfort. Instead, cold compresses before feeding or gentle massage toward the nipple during feeding is more effective in relieving engorgement.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an infant with tetralogy of Fallot. During a blood draw the nurse observes the infant becoming pale and lethargic with circumoral cyanosis and diminished peripheral pulses. Which action should the nurse take next?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

Patient Data Exhibits Which findings indicate an improvement in the client’s condition?

During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

A client who is in labor states, "I think my water just broke?" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

In assessing a 1-day-old male newborn, the nurse observes that the scrotal sac is large, swollen, smooth, and taut. Which assessment technique should the nurse perform to determine if the newborn has a hydrocele?

A nurse in the transition nursery is assigned to care for four recently delivered infants. Which infant should the nurse assess first? Reference Range: Blood glucose/neonate [30 to 60 mg/dL (1.7 to 3.3 mmol/L)]

The nurse is caring for a preschooler with spina bifida admitted with a febrile urinary tract infection. Which action should the nurse prioritize to minimize complications of vesicoureteral reflux?