A school nurse is talking with a 13-year-old non-binary student at their annual health screening visit. Which statement by the adolescent will the nurse prioritize?

I haven't had a growth spurt yet, and all my friends are taller than me.

My parents treat me like a baby sometimes.

None of the kids at this school like me, and I don't like them either.

There's a big project due by the end of the month, and I'm really stressed about it.

Answer and Explanation

The Correct Answer is C

Choice A reason: Concerns about physical development, such as not having had a growth spurt yet, are common among adolescents. While this statement indicates some distress, it is generally considered a normal part of adolescent development and may not require immediate intervention.

Choice B reason: Feeling infantilized by parents is also a common issue among teenagers. This can be addressed through communication and support, but it is not typically an urgent matter.

Choice C reason: Statements about social isolation and feeling disliked by peers can be indicative of significant emotional distress or even depression. This statement warrants immediate attention to assess the adolescent's mental health and provide necessary support or intervention.

Choice D reason: Stress related to academic pressures, such as a big project, is common among students. While it is important to address stress management, it does not typically indicate an immediate risk to the student's well-being.

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Correct Answer is ["64"]

Explanation

To calculate the maintenance IV fluid rate for a child, we typically use the Holliday-Segar formula:

For the first 10 kg of weight: 100 ml/kg/day
For the next 10 kg of weight: 50 ml/kg/day
For any additional weight: 20 ml/kg/day

The weight of the child is 48 pounds, which is approximately 21.8 kg (since 1 pound = 0.45 kg).

Using the formula:

First 10 kg: 100 ml/kg/day = 1000 ml/day
Next 10 kg: 50 ml/kg/day = 500 ml/day
Remaining 1.8 kg: 20 ml/kg/day = 36 ml/day

Total = 1000 ml + 500 ml + 36 ml = 1536 ml/day

To find the rate in ml/hr: 1536 ml/day ÷ 24 hours/day = 64 ml/hr

A. Obtain an arterial blood gas. B. Ensure thermoregulation. C. Administer oxygen as needed. D. Insert an orogastric tube. E. Keep the head in a sniffing position.

Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Obtaining an arterial blood gas is not typically a routine intervention immediately following a caesarean section. Arterial blood gas measurements are usually performed if there is a specific indication or concern about the baby's respiratory status or acid-base balance. Routine care focuses on stabilizing and assessing the baby rather than performing invasive procedures unless clinically indicated.

Choice B reason: Ensuring thermoregulation is a crucial intervention for newborns, especially those delivered by caesarean section. Maintaining an appropriate body temperature is essential to prevent hypothermia, which can lead to complications such as metabolic disturbances and respiratory issues. The nurse should use measures like pre-warmed blankets and radiant warmers to keep the baby warm and stable.

Choice C reason: Administering oxygen as needed is an important intervention to ensure the baby's oxygenation and respiratory stability. Newborns delivered by caesarean section may have transient respiratory difficulties due to the lack of the natural squeeze through the birth canal, which helps clear the lungs of fluid. Monitoring the baby's respiratory status and providing supplemental oxygen if necessary is vital for their well-being.

Choice D reason: Inserting an orogastric tube is not a standard routine intervention immediately after a caesarean section unless there is a specific indication, such as if the baby has difficulty feeding, significant respiratory distress, or gastrointestinal issues. Routine care focuses on more immediate stabilization measures unless clinical signs suggest the need for an orogastric tube.

Choice E reason: Keeping the head in a sniffing position is important for maintaining an open airway and ensuring effective ventilation. The sniffing position aligns the airway and promotes optimal breathing. This position is particularly useful for newborns who may have respiratory difficulties or require resuscitation efforts, ensuring that their airway remains patent and clear.

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A school nurse is talking with a 13-year-old non-binary student at their annual health screening visit. Which statement by the adolescent will the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is calculating maintenance IV fluid requirements for a child who weighs 48 pounds. Using the continuous fluid maintenance formula, calculate the rate (ml/hr) the nurse will set the pump? Round to the nearest whole number. Enter the number only, no units.

Correct Answer is ["64"]

Explanation

The nurse is preparing for the care of a baby about to be delivered by caesarean section. What interventions will the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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