The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?
whitish vesicles located across the chest
Small blue-white spots with a red base found on the buccal mucosa
Pinpoint petechiae noted on both legs
Petechiae spots that are reddish and pinpoint on the soft palate
The Correct Answer is B
A. Whitish vesicles located across the chest:
Incorrect: This description does not match the characteristic appearance or location of Koplik's spots in measles.
B. Small blue-white spots with a red base found on the buccal mucosa:
Correct Answer: Koplik's spots are small, blue-white spots with a red base that typically appear on the buccal mucosa (inner lining of the cheeks). These spots are characteristic of measles and are considered a diagnostic feature.
C. Pinpoint petechiae noted on both legs:
Incorrect: Petechiae are small, reddish-purple spots that result from bleeding under the skin. They are not characteristic of Koplik's spots in measles.
D. Petechiae spots that are reddish and pinpoint on the soft palate:
Incorrect: While petechiae can occur in various conditions, they are not characteristic of Koplik's spots in measles. Koplik's spots specifically manifest as small blue-white spots on the buccal mucosa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Has the child had any difficulty swallowing food?"
Explanation:
One potential long-term effect of cleft palate repair is difficulty with swallowing or feeding. Cleft palate repair aims to improve the child's ability to eat and speak, but some children may continue to face challenges with swallowing or have a history of difficulty feeding.
B. "Does the child play with an imaginary friend?"
Explanation: Imaginary play is not specifically related to the long-term effects of cleft palate repair. This question does not provide information about the physical outcomes of the surgical repair.
C. "Does the child respond when called by name?"
Explanation: Responsiveness to being called by name is a general developmental question but does not specifically address the long-term effects of cleft palate repair.
D. "Was the child recently treated for pneumonia?"
Explanation: While respiratory issues can be associated with cleft palate, this question focuses on a recent event rather than the long-term effects. Asking about difficulty swallowing or feeding may provide more information about ongoing concerns related to the cleft palate repair.
Correct Answer is D
Explanation
A. "Newborns are abdominal breathers."
Explanation: While it is true that newborns primarily use their diaphragms for breathing (abdominal breathing), this statement does not specifically address why the respiratory rate should be counted for a full minute.
B. "Activity will increase the respiratory rate."
Explanation: This statement acknowledges that activity can influence the respiratory rate but does not specifically address the need to count for a full minute to capture the irregular patterns.
C. "Newborns do not expand their lungs fully with each respiration."
Explanation: This statement highlights a characteristic of newborn respiratory physiology but does not specifically explain the importance of counting the respiratory rate for a full minute.
D. "The rate and rhythm of breath are irregular in newborns."
Explanation:
Newborns often have irregular breathing patterns, and counting the respiratory rate for a full minute helps capture the variations in rate and rhythm accurately. Newborns may experience periods of rapid breathing followed by periods of slower breathing, and their respiratory patterns can be influenced by sleep-wake cycles, feeding, and other factors. Counting for a full minute provides a more comprehensive and representative assessment of the newborn's respiratory status.
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