Nokea
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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The nurse is caring for a toddler with autism spectrum disorder and failure to thrive. Which intervention should the nurse implement?
- A. Provide structured meal times.
- B. Offer food even if disinterested.
- C. Incorporate play during meals.
- D. Allow multiple food choices.
Correct Answer: A
Rationale: Structured meal times promote routine and reduce sensory overload, aiding feeding in children with autism spectrum disorder.
Which snack selected by a school-aged child with gastroesophageal reflux indicates to the nurse that the child understands the dietary restrictions?
- A. Sugar cookies.
- B. Pizza.
- C. Tacos.
- D. Chocolate milkshake.
Correct Answer: A
Rationale: Sugar cookies are low-fat and low-sugar, suitable for gastroesophageal reflux, unlike high-fat or acidic options.
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.
A child receives a prescription for loratadine 5 mg by mouth once day. The bottle is labelled 'Loratadine for Oral Suspension, USP 5 mg per 5 mL.' How many teaspoons should the nurse instruct the parent to administer with each dose?
- A. 1 teaspoon
Correct Answer: A
Rationale: 5 mg of loratadine corresponds to 5 mL (1 teaspoon) of the suspension, as per the concentration provided.
The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Audible heart murmur.
- B. Heart rate of 162 beats/minute.
- C. Poor oral intake and suckling effort.
- D. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours.
Correct Answer: C
Rationale: Poor oral intake and suckling effort indicate feeding difficulties, which can lead to dehydration and poor weight gain, requiring immediate reporting.