Nokea
The nurse is assessing an infant and notes that the infant's urine has a mousy or musty odor. What would the nurse suspect?
- A. Maple syrup urine disease
- B. Tyrosinemia
- C. Phenylketonuria
- D. Trimethylaminuria
Correct Answer: C
Rationale: The correct answer is C: Phenylketonuria (PKU). PKU is suggested by a mousy or musty odor of the urine, which is caused by the inability to metabolize phenylalanine. Choice A, Maple syrup urine disease, is characterized by a sweet-smelling urine. Choice B, Tyrosinemia, typically presents with cabbage-like odor in the urine. Choice D, Trimethylaminuria, is associated with a fishy odor in the urine, breath, and sweat.
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What type of play does a caregiver expect when observing a toddler in a playroom with other children?
- A. Parallel
- B. Solitary
- C. Cooperative
- D. Competitive
Correct Answer: A
Rationale: When observing a toddler in a playroom with other children, a caregiver would expect to witness parallel play. Parallel play is common among toddlers, where they play alongside but not directly with other children. This type of play is characterized by children engaging in similar activities near each other without interactive or cooperative play. Solitary play (Choice B) involves a child playing alone, while cooperative play (Choice C) involves children playing together towards a common goal. Competitive play (Choice D) involves activities where children compete against each other.
A 34-year-old woman, who is 36 weeks pregnant, is having a seizure. After you protect her airway and ensure adequate ventilation, you should transport her
- A. on her left side
- B. in the prone position
- C. in the supine position
- D. in a semi-sitting position
Correct Answer: A
Rationale: When a pregnant woman experiences a seizure, it is crucial to transport her on her left side. This position helps to improve blood flow to the fetus by preventing compression of the inferior vena cava, reducing the risk of further complications. Placing her in the prone position (lying face down) or supine position (lying on her back) may compromise blood flow to the fetus and lead to adverse outcomes. Similarly, transporting her in a semi-sitting position may not provide the optimal circulation needed for both the woman and the fetus during this critical situation.
The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?
- A. Risk for impaired skin integrity due to cast and location.
- B. Deficient knowledge related to cast care.
- C. Risk for delayed development related to immobility.
- D. Self-care deficit related to immobility.
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity due to cast and location. When caring for a child with a long-leg hip spica cast, the priority nursing diagnosis is the risk for impaired skin integrity. This is because the child's limited mobility and the pressure from the cast can lead to skin breakdown and complications. Choice B is incorrect as while education is essential, it is not the priority when immediate physical risks are present. Choice C is incorrect because while immobility can impact development, the immediate concern is preventing complications from the cast. Choice D is incorrect as it focuses on self-care deficits rather than the physical risk of skin integrity issues.
The nurse is caring for a 3-day-old girl with Down syndrome whose mother had no prenatal care. What is the priority nursing diagnosis?
- A. Imbalanced nutrition, less than body requirements related to the effects of hypotonia
- B. Deficient knowledge related to the presence of a genetic disorder
- C. Delayed growth and development related to cognitive impairment
- D. Impaired physical mobility related to poor muscle tone
Correct Answer: A
Rationale: The priority nursing diagnosis for a newborn with Down syndrome is often related to feeding difficulties due to hypotonia, making imbalanced nutrition the primary concern. Hypotonia, or poor muscle tone, can lead to challenges with feeding and, subsequently, affect the baby's nutritional intake. While choices B, C, and D may also be concerns for a child with Down syndrome, addressing the immediate need for adequate nutrition takes precedence to ensure the infant's well-being and growth.
A healthcare professional plans to discuss childhood nutrition with a group of parents whose children have Down syndrome in an attempt to minimize a common nutritional problem. What problem should be addressed?
- A. Rickets
- B. Obesity
- C. Anemia
- D. Rumination
Correct Answer: B
Rationale: Childhood obesity is a prevalent issue in children with Down syndrome due to factors such as decreased physical activity, slower metabolism, and potential overeating tendencies. Addressing obesity is crucial to promoting healthy lifestyles and preventing associated health complications. Rickets, a condition caused by a deficiency of vitamin D, is not commonly associated with Down syndrome. While anemia can occur in individuals with Down syndrome, obesity is a more common concern. Rumination, the regurgitation of food without nausea, is not a typical nutritional problem in children with Down syndrome.