Nokea
The nurse explains that what is the optimal time for testing for phenylketonuria?
- A. In the first 24 hours of life
- B. After 2 to 3 days
- C. At 4 to 6 weeks of age
- D. At 2 months of age
Correct Answer: B
Rationale: Testing for phenylketonuria at 48 to 72 hours allows sufficient protein intake to reduce false-negative results.
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Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair at which time?
- A. Immediately after birth
- B. By 3 months of age
- C. After 12 months of age
- D. Varies in every case
Correct Answer: B
Rationale: A cleft lip is repaired by 3 months of age when weight gain is established and the infant is free of infection.
What is the most appropriate nursing action for the infant having phototherapy?
- A. Cover the infant's head with a hat.
- B. Dress the infant lightly in a T-shirt.
- C. Keep the infant's eyes covered.
- D. Reposition the infant at least every 4 to 8 hours.
Correct Answer: C
Rationale: The infant's eyes are protected with patches during phototherapy to prevent damage from high-intensity lights.
What should the nurse assess for with this neonate?
- A. Hypoglycemia
- B. Erythroblastosis fetalis
- C. Intracranial hemorrhage
- D. Pancreatic failure
Correct Answer: A
Rationale: The newborn of a mother with diabetes is prone to hypoglycemia due to hyperinsulinism after the abrupt loss of maternal glucose.
How should the nurse position this infant?
- A. Prone, with the head of the bed elevated
- B. Supine, with the head flat
- C. Side-lying on the operative side
- D. In a semi-Fowler's position
Correct Answer: D
Rationale: A semi-Fowler's position promotes drainage from the ventricles through the shunt in an infant with bulging fontanelles post-ventriculoperitoneal shunt.
What characteristics are typical in a child diagnosed with Down syndrome?
- A. Close-set eyes
- B. Simian creases
- C. Wide-spaced front teeth
- D. Protruding tongue
- E. Curved, small fingers
Correct Answer: A,B,D,E
Rationale: Children with Down syndrome have close-set upturned eyes, simian creases, protruding tongue, and curved, small fingers.