A newborn with a repaired gastroschisis is transferred to the paediatric unit after several days in the paediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Offer a pacifier for non-nutritive sucking.
- B. Use sterile technique during feedings.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Speak to the healthcare provider about instituting physical therapy.
Correct Answer: A
Rationale: Non-nutritive sucking via a pacifier promotes oral motor skill development, supporting normal feeding behaviors critical for growth.
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The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
- A. Have the child blow a cotton ball and have the parent catch it.
- B. Place a toy in the child's hands while listening to the breath sounds.
- C. Offer the child bubbles before the stethoscope is placed.
- D. Allow the child to use a stethoscope on a stuffed animal.
Correct Answer: D
Rationale: Allowing the child to use a stethoscope on a stuffed animal familiarizes them with the procedure, increasing cooperation.
A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?
- A. Ask the boy to describe a typical day at school.
- B. Compare the child's vital signs over the past three weeks.
- C. Conduct a complete neurological assessment.
- D. Counsel the parents to pay more attention to the child.
Correct Answer: A
Rationale: Describing a typical school day helps identify potential stressors causing the symptoms, guiding further intervention.
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
- A. Apply lotion to hands and feet.
- B. Encourage the child to rest when possible.
- C. Place the child in a quiet environment.
- D. Make a list of foods that the child likes.
Correct Answer: C
Rationale: A quiet environment reduces sensory stimulation, alleviating irritability, which is a primary concern in Kawasaki disease.
The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?
- A. Rebound tenderness in the left lower abdominal quadrant.
- B. Stool that consists of mucus and blood.
- C. Olive-size mass in the epigastric area.
- D. Frequent burping accompanied by poor feeding.
Correct Answer: C
Rationale: An olive-size mass in the epigastric area is characteristic of pyloric stenosis, associated with projectile vomiting.
The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appear slightly yellow. Additionally, urine in his diaper appears tea-colored. This child should receive follow-up assessment for what condition?
- A. Intussusception.
- B. Biliary atresia.
- C. Hirschsprung's disease.
- D. Huntington's disease.
Correct Answer: B
Rationale: Jaundice and tea-colored urine suggest biliary atresia, requiring urgent follow-up to prevent liver damage.
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