Nokea
Which intervention should the nurse implement to maintain the skin integrity of the preterm newborn?
- A. Cleanse skin with a gentle alkaline-based soap and water.
- B. Cleanse skin with a neutral pH solution only when necessary.
- C. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
- D. Avoid cleaning skin.
Correct Answer: B
Rationale: Preterm newborns have delicate skin that is more susceptible to damage and irritation. Using a neutral pH solution for cleansing helps to maintain the skin's natural acidity and prevent disruption of the skin barrier. It is important to avoid over-bathing or using harsh alkaline-based soaps that can strip the skin of its natural oils and cause dryness or irritation. Cleansing the skin only when necessary helps to protect the fragile skin of preterm newborns and reduce the risk of skin breakdown or injury.
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The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
- A. Serum potassium level of 4.9mEq/L
- B. Temperature of 99.2F (37.3C)
- C. Serum sodium level of 135mEq/L
- D. Urine output of 20mL/hour
Correct Answer: D
Rationale: A low urine output of 20mL/hour shortly after kidney transplant surgery is a critical finding that must be reported to the physician immediately. Adequate urine output is essential to ensure proper kidney function and the body's ability to eliminate waste products and regulate electrolyte levels. A urine output of less than 30mL/hour is considered oliguria, which may indicate decreased kidney function or potential complications such as acute kidney injury. Therefore, prompt evaluation and intervention are necessary to prevent further kidney damage or complications in the client.
Mr. Go had a post-kidney transplant. What should the nurse immediately assess?
- A. fluid and electrolyte imbalances
- B. hepatotoxicity
- C. infection
- D. respiratory complications
Correct Answer: A
Rationale: After a kidney transplant, it is essential for the nurse to immediately assess for fluid and electrolyte imbalances in the recipient. The transplanted kidney may take some time to start functioning optimally, and during this period, the body may not be able to regulate fluid and electrolyte balance effectively. Monitoring for signs of fluid overload, electrolyte disturbances, and kidney function is crucial to prevent complications such as dehydration, electrolyte abnormalities, and organ rejection. Early detection of these imbalances allows for prompt intervention and prevention of potential complications.
Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is the diagnosis of SIDS most likely?
- A. At 1 to 2 years of age
- B. At I week to 1 year of age, peaking at 2 to 4 months
- C. At 6 months to 1 year of age, peaking at 10 months
- D. At 6 to 8 weeks of age
Correct Answer: B
Rationale: Sudden infant death syndrome (SIDS) is most likely to occur between the ages of 1 week to 1 year, with the highest risk period being between 2 to 4 months of age. While SIDS can occur up to the age of 1 year, the peak incidence is during the first 6 months of life. It is important to follow safe sleep practices, such as placing infants on their backs to sleep, to reduce the risk of SIDS during this vulnerable period.
A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drug falls into this category?
- A. Procainamide (Pronestyl)
- B. Phenytoin (Dilantin)
- C. Azathioprine (Imuran)
- D. Allopurinol (Zyloprim)
Correct Answer: B
Rationale: Gingival hyperplasia, or overgrowth of gum tissue, is a common side effect associated with certain medications, particularly anti-seizure medications like phenytoin (Dilantin). This side effect can be minimized through good oral hygiene practices, such as regular brushing and flossing of the teeth. The client must pay extra attention to oral care while taking phenytoin in order to prevent or reduce the severity of gingival hyperplasia. It is important for healthcare providers to educate clients on the importance of oral hygiene with medications associated with this side effect.
Which is characteristic of newborns whose mothers smoked during pregnancy?
- A. Large for gestational age
- B. Preterm, but size appropriate for gestational age
- C. Growth retardation in weight only
- D. Growth retardation in weight, length, and head circumference
Correct Answer: D
Rationale: Newborns whose mothers smoked during pregnancy often display growth retardation in weight, length, and head circumference. Maternal smoking is associated with intrauterine growth restriction, leading to reduced size parameters at birth. This can result in newborns being smaller in weight, length, and head circumference compared to newborns of mothers who did not smoke during pregnancy. Smoking during pregnancy can have negative effects on the developing fetus, contributing to various health risks and growth abnormalities in newborns.