Nokea
A nurse is planning care for a preterm newborn. Which interventions should the nurse implement for skin care? (Select all that apply.)
- A. Use cleaning agents with neutral pH.
- B. Rub skin during drying.
- C. Use adhesive remover solvent when removing tape.
- D. Avoid removing adhesives for at least 24 hours.
Correct Answer: A
Rationale: Using cleaning agents with neutral pH is important for the delicate skin of a preterm newborn to prevent irritation and damage.
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The MOST common cause of sleeping difficulty in the first 2 months of life is
- A. gastro-esophageal reflux
- B. colic
- C. formula intolerance
- D. developmentally self-resolving sleeping behavior
Correct Answer: B
Rationale: Colic is a frequent cause of sleep difficulties in young infants.
Which of the ff diets does the nurse recommend for clients with hypertension under the physicians guidance?
- A. The Food Guide Pyramid
- B. The South Beach Diet
- C. The Step One Diet
- D. The Dash diet
Correct Answer: D
Rationale: The Dietary Approaches to Stop Hypertension (DASH) diet is recommended by healthcare professionals, including nurses, for clients with hypertension. This diet emphasizes consuming fruits, vegetables, whole grains, lean proteins, and low-fat dairy products while limiting sodium, saturated fats, and cholesterol. These dietary components are known to help lower blood pressure and improve overall health. The DASH diet has been proven effective in numerous studies and is endorsed by organizations like the American Heart Association for managing hypertension. It is important for clients to follow the DASH diet under the guidance of a physician to ensure it is tailored to their individual needs and health status.
The LEAST important advice for a 2-month-old baby with excessive crying is
- A. master the situation in relaxed manner
- B. adhere to precry cues
- C. change milk formula
- D. avoid sensory overstimulation
Correct Answer: C
Rationale: Changing formula may not address refusal due to developmental factors.
You are evaluating a 6-mo-old girl with a firm right suprarenal mass. Histologically, there is no bony involvement, 10% bone marrow involvement, subcutaneous nodules involvement, and massive abdominal mass. The N-myc oncogene is not amplified. According to the international neuroblastoma staging system, the infant is stratified as
- A. stage I
- B. stage II A
- C. stage III
- D. stage IV S
Correct Answer: D
Rationale: Stage IV S refers to infants <1 year with localized primary tumor, distant metastases limited to liver, skin, or bone marrow (with <10% involvement), and no amplification of N-myc.
Which action best explains the main role of surfactant in the neonate?
- A. Assists with ciliary body maturation in the upper airways
- B. Helps maintain a rhythmic breathing pattern
- C. Promotes clearing mucus from the respiratory tract
- D. Helps the lungs remain expanded after the initiation of breathing
Correct Answer: D
Rationale: Surfactant plays a crucial role in the neonate by helping the lungs remain expanded after the initiation of breathing. Surfactant is a substance produced by type II alveolar cells in the lungs that reduces surface tension in the alveoli. By lowering surface tension, surfactant prevents the alveoli from collapsing during expiration, thereby helping the lungs to remain expanded and functional. This function is particularly important in neonates, whose lungs are not yet fully developed and may have difficulty maintaining lung expansion without adequate levels of surfactant. Failure to produce enough surfactant can lead to respiratory distress syndrome in premature infants.