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A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
- A. I should not remove the yellow exudate on the end of the penis.
- B. I will clean his penis with each diaper change.
- C. The circumcision will heal completely within a couple of weeks.
- D. I can give him a tub bath in two days.
Correct Answer: D
Rationale: The correct answer is D: "I can give him a tub bath in two days." This statement indicates the need for further clarification because newborns who have undergone circumcision should avoid submerging the area in water until it is fully healed to prevent infection. Tub baths should be avoided until the circumcision site has completely healed, which usually takes about 7-10 days. It is important to keep the area clean and dry during this time to promote healing.
Explanation for other choices:
A: "I should not remove the yellow exudate on the end of the penis." - Correct, as it is normal and part of the healing process.
B: "I will clean his penis with each diaper change." - Correct, as keeping the area clean helps prevent infection.
C: "The circumcision will heal completely within a couple of weeks." - Correct, as the healing process typically takes around 1-2 weeks.
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A new mother is crying in her room. She tells the nurse that her new baby boy has enlarged breasts and she thinks that there is something wrong. How should the nurse respond?
- A. Enlarged breasts are common for both boys and girls. It will go away.
- B. Let me look at the baby for you.
- C. Everything is going to be just fine. Your baby is healthy.
- D. You should ask your doctor about that.
Correct Answer: A
Rationale: The correct answer is A. Enlarged breasts in newborn boys and girls are a common physiological phenomenon called breast engorgement due to maternal hormones. The nurse should reassure the mother that it is normal and will resolve on its own. Choice B is unnecessary as the nurse already knows the cause. Choice C is vague and does not address the mother's concern directly. Choice D is not ideal as the nurse can provide basic information on the issue.
A nurse is monitoring a 9-year-old child on the first postoperative day following abdominal surgery.
- A. "Poker chip tool"'
- B. "FACES rating scale"'
- C. "Visual analog scale"'
- D. "Numerical 1 to 10 rating scale"'
Correct Answer: B
Rationale: The correct answer is B: "FACES rating scale." This tool uses facial expressions to assess pain in children, making it suitable for a 9-year-old who may find it challenging to express pain verbally. The other choices are not as appropriate for this age group postoperatively: A is not a recognized pain assessment tool, C and D may be too abstract for a child, and E-G are missing options.
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non pharmacological interventions should the nurse include in the plan of care for lactation suppression?
- A. Place warm, moist packs on the breast.
- B. Apply cabbage leaves to the breast.
- C. Wear a loose-fitting bra.
- D. Put green tea bags on the breasts.
Correct Answer: B
Rationale: The correct answer is B: Apply cabbage leaves to the breast. Cabbage leaves have been shown to help with lactation suppression due to their anti-inflammatory properties. Placing cabbage leaves on the breasts can help reduce milk supply by decreasing blood flow to the area. This method is safe, inexpensive, and easily accessible.
Choice A (Place warm, moist packs on the breast) is incorrect as warmth can actually stimulate milk production. Choice C (Wear a loose-fitting bra) is also incorrect as it does not directly address lactation suppression. Choice D (Put green tea bags on the breasts) is not effective for lactation suppression and may not be safe for the newborn if ingested.
For a pregnant adolescent who is anemic, which foods should the nurse include in the client's dietary plan to increase iron levels?
- A. Milk and fish
- B. Chicken and cottage cheese
- C. Orange juice and apricots
- D. Pickles and peanut butter sandwiches
Correct Answer: C
Rationale: The correct answer is C: Orange juice and apricots. Orange juice is a good source of Vitamin C, which enhances iron absorption. Apricots are high in iron, helping to increase iron levels in the body. Milk and fish (choice A) contain little iron. Chicken and cottage cheese (choice B) are not significant sources of iron. Pickles and peanut butter sandwiches (choice D) lack iron and Vitamin C.
A nurse is caring for a toddler who is in an oxygen tent. Which of the following actions should the nurse take in order to promote comfort while maintaining the child's safety?
- A. Give the child a stuffed animal and car with rubber wheels to play with.
- B. "Give the child a stuffed animal and car with rubber wheels to play with."'
- C. "Change the bedding and the child's clothing frequently or as often as needed."'
- D. "Tuck the bottom of the tent under the mattress on three sides,leaving one side open so the child can look out."'
Correct Answer: C
Rationale: The correct answer is C. Changing the bedding and the child's clothing frequently promotes comfort by ensuring cleanliness and preventing skin irritation. This action also maintains the child's safety by reducing the risk of infections and skin breakdown. Giving a stuffed animal and a car with rubber wheels (Choice A) may pose a choking hazard. Tucking the bottom of the tent under the mattress on three sides (Choice D) may restrict airflow and increase the risk of suffocation.