Nokea
A client who is pregnant and has phenylketonuria (PKU) is receiving teaching from a nurse. Which of the following foods should the nurse instruct the client to eliminate from her diet?
- A. Peanut butter
- B. Potatoes
- C. Apple juice
- D. Broccoli
Correct Answer: A
Rationale: The correct answer is A: Peanut butter. Phenylketonuria (PKU) is a metabolic disorder where the body can't process phenylalanine found in protein foods. Peanut butter is high in protein and contains phenylalanine, so it should be eliminated from the client's diet. Potatoes, apple juice, and broccoli are low in protein and do not contain high levels of phenylalanine, so they do not need to be eliminated. It is crucial for the client to avoid foods high in phenylalanine to prevent the buildup of toxic levels in the body, which can lead to serious health issues.
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A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?
- A. Apply cold compresses to the affected extremity
- B. Massage the affected extremity
- C. Allow the client to ambulate
- D. Measure leg circumferences
Correct Answer: D
Rationale: The correct answer is D - Measure leg circumferences. This is important in assessing for changes in swelling, which can indicate worsening thrombophlebitis. Monitoring leg circumferences helps in early detection of complications like deep vein thrombosis. Applying cold compresses (A) can worsen vasoconstriction, massage (B) can dislodge clots, and allowing ambulation (C) can increase the risk of clot migration.
A healthcare professional is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the healthcare professional anticipate administering?
- A. Ofloxacin
- B. Nystatin
- C. Erythromycin
- D. Ceftriaxone
Correct Answer: C
Rationale: The correct answer is C: Erythromycin. Erythromycin is the standard treatment for preventing ophthalmia neonatorum, a condition caused by Neisseria gonorrhoeae or Chlamydia trachomatis. It is a broad-spectrum antibiotic that effectively prevents bacterial infections in newborns. Ofloxacin (A) is a fluoroquinolone antibiotic not typically used in newborns. Nystatin (B) is an antifungal medication used for treating fungal infections, not bacterial infections like ophthalmia neonatorum. Ceftriaxone (D) is a cephalosporin antibiotic used for various bacterial infections, but it is not the first-line treatment for preventing ophthalmia neonatorum.
When reinforcing teaching with a group of new parents about proper techniques for bottle feeding, which of the following instructions should be provided?
- A. Burp the newborn at the end of the feeding
- B. Hold the newborn close in a supine position
- C. Keep the nipple full of formula throughout the feeding
- D. Refrigerate any unused formula
Correct Answer: C
Rationale: Rationale:
C is correct because keeping the nipple full of formula throughout the feeding helps prevent the baby from swallowing air, reducing the risk of gas and colic. A is incorrect because burping should be done mid-feeding. B is incorrect because newborns should be held in an upright position while feeding to prevent choking. D is incorrect because unused formula should be discarded within 1-2 hours, not refrigerated.
A caregiver is being taught about bottle feeding a newborn. Which of the following statements by the caregiver indicates a need for further instruction?
- A. I will keep the baby's head elevated while feeding.
- B. I will allow the baby to burp several times during each feeding.
- C. I will tilt the bottle to prevent air from entering as the baby sucks.
- D. My baby will have soft, formed yellow stools.
Correct Answer: C
Rationale: The correct answer is C. Tilt the bottle to prevent air from entering as the baby sucks is incorrect. It is important not to tilt the bottle as it can cause the baby to swallow air, leading to gas and discomfort. A: Keeping the baby's head elevated helps prevent choking. B: Allowing the baby to burp reduces gas and discomfort. D: Soft, formed yellow stools indicate a healthy digestive system. Thus, C is the only statement that may lead to issues and requires further instruction.
When checking for the Moro reflex in a newborn, what action should the nurse take?
- A. Hold the newborn vertically under arms and allow one foot to touch the table.
- B. Stimulate the pads of the newborn's hands with stroking or massage.
- C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot.
- D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.
Correct Answer: D
Rationale: The correct answer is D because the Moro reflex is elicited by sudden head movement or loud noise, causing the infant to extend their arms, then bring them back in a hugging motion. By holding the newborn in a semi-sitting position and allowing their head and trunk to fall backward, the nurse can observe the Moro reflex. Choices A, B, and C do not correctly elicit the Moro reflex as they involve different stimuli or movements that do not trigger the characteristic response of arm extension followed by flexion.