A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Apply pressure to the lacrimal punctum.
Place the child in a sitting position.
Instill the drops of medication.
Pull the lower eyelid downward.
The Correct Answer is B,D,C,A
Rationale:
B. Place the child in a sitting position: Positioning the child upright or with the head slightly tilted back promotes comfort, stability, and proper visualization of the conjunctival sac for accurate drop placement.
D. Pull the lower eyelid downward: This creates a conjunctival pocket that holds the medication and allows it to spread evenly over the eye surface without spilling.
C. Instill the drops of medication: Instillation should occur after exposing the conjunctival sac to ensure the medication reaches the target area. The dropper should not touch the eye to prevent contamination.
A. Apply pressure to the lacrimal punctum: This step is performed last to prevent systemic absorption of the medication by blocking the nasolacrimal duct. Holding gentle pressure for about 1 minute helps maximize the local effect of the drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Both fontanels are the same size: Fontanels differ in size and shape; the anterior is larger and diamond-shaped, while the posterior is smaller and triangular. Expecting them to be the same size is inaccurate.
B. The anterior fontanel is open: The anterior fontanel typically remains open until about 12–18 months of age. At 8 months, an open anterior fontanel is an expected finding and indicates normal skull development.
C. The posterior fontanel is open: The posterior fontanel usually closes by 6–8 weeks of age. An open posterior fontanel at 8 months may indicate delayed closure and should be evaluated further.
D. Both fontanels show molding: Molding refers to overlapping of cranial bones during birth. At 8 months, molding should no longer be present; its presence is not a normal finding at this age.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Rationale:
- Polyhydramnios: Excess amniotic fluid can overdistend the uterus, reducing its ability to contract effectively after delivery, which increases the risk of uterine atony and postpartum hemorrhage.
- Prolonged rupture of membranes: A long duration of ruptured membranes increases the risk of bacteria ascending into the uterus, which can lead to endometritis and systemic infection postpartum.
- Prenatal anemia: Low hemoglobin levels reduce oxygen delivery to tissues and impair the immune response, increasing susceptibility to infections such as endometritis or wound infection after cesarean birth.
- High parity: Multiple pregnancies can cause stretching and weakening of the uterine muscle, which may result in inadequate contraction postpartum, predisposing the client to uterine atony.
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