Nokea
. A new mother of a full-term, 7-lb newborn asks the nurse how to ensure that her baby is taking the correct amount of formula at each feeding. The nurse explains that the infant needs approximately 3 ounces of fluid per pound of body weight per day. How many ounces of formula should her infant be eating every 4 hours? _________ ounces (Record your answer to the nearest tenth.)
Correct Answer: 3.5
Rationale: Multiplying 3 oz by 7 lb = 21 oz/day. Dividing 21 oz by 6 feedings (every 4 hours) = 3.5 oz per feeding.
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Because of the length of time the client must remain in skeletal traction, the nurse correctly assesses for evidence of skin breakdown in which area?
- A. Over the child's calves
- B. Over the child's scapulae
- C. On the child's knees
- D. On the child's buttocks
Correct Answer: D
Rationale: Prolonged immobility in traction increases pressure on the buttocks, a common site for skin breakdown due to constant contact with the bed.
The parents of the child with juvenile rheumatoid arthritis (JRA) ask the nurse why the child cannot have aspirin. The parents further explain that they have heard that aspirin is used in the elderly for arthritis and the use of the patients. The nurse correctly explains that children with JRA are given different medications than adults with arthritis and explains that the toxic effects of aspirin include which manifestations?
- A. Constipation, weight gain, and fluid retention
- B. Ringing in the ears, nausea, and vomiting
- C. Anorexia, weight loss, and double vision
- D. Headache, dry mouth, and dental cavities
Correct Answer: B
Rationale: Aspirin in children can cause toxicity, including tinnitus, nausea, and vomiting, and is avoided due to the risk of Reye's syndrome, especially in children with viral infections.
The nurse correctly advises the parents to avoid administering medications containing which ingredient to their child who has hemophilia?
- A. Acetaminophen
- B. Aspirin
- C. Ibuprofen
- D. Penicillin
Correct Answer: B
Rationale: Aspirin inhibits platelet function and increases bleeding risk, which is dangerous for a child with hemophilia, a condition characterized by impaired clotting.
The primiparous client,who delivered a term newborn is a lesbian,achieved her pregnancy via artificial insemination and is in a monogamous relationship with a female partner. Which intervention should the nurse add to the newborn’s care plan?
- A. Avoid acknowledging the client’s lesbian relationship.
- B. Encourage the client’s partner to participate in newborn cares.
- C. Ask the partner to leave the room when the newborn is present.
- D. Avoid telling the newborn’s caregivers about the client’s situation.
Correct Answer: B
Rationale: Encouraging the partner to participate in newborn care shows respect and promotes bonding similar to heterosexual partners. Ignoring the relationship or excluding the partner is disrespectful.
When preparing the adolescent for the examination, the nurse correctly explains that a specimen should be collected and sent to the laboratory. Which specimen should the nurse collect?
- A. Blood sample
- B. Urine sample
- C. Vaginal smear
- D. Biopsy of the cervix
Correct Answer: C
Rationale: A vaginal smear is appropriate for diagnosing gonorrhea in females, allowing culture or nucleic acid testing of cervical or vaginal secretions to detect Neisseria gonorrhoeae.