Nokea
The nurse is discharging the 3-day-old term newborn with a right-sided cephalohematoma. The nurse should instruct the parents to observe their infant closely over the next week for the development of which problem associated with the cephalohematoma?
- A. Jaundice
- B. Difficulty feeding
- C. Pale extremities
- D. Bulging on the right side of the head with crying
Correct Answer: A
Rationale: Cephalohematoma resolution causes RBC hemolysis leading to jaundice. It doesn’t affect feeding cause paleness or bulge with crying.
You may also like to solve these questions
The nurse assesses that the 8-hour-old infant’s axillary temperature is 97°F (36.1°C). Which intervention should the nurse implement first?
- A. Document the findings as abnormal.
- B. Place the infant under a radiant warmer.
- C. Feed the infant formula that is warmed.
- D. Call the HCP to report the temperature.
Correct Answer: B
Rationale: An axillary temperature of 97°F is below the normal range (97.7°F–98.9°F). The infant should be gradually rewarmed under a radiant warmer. Documentation follows intervention feeding warm formula is unnecessary and HCP notification is needed only if warming fails.
Which instruction should the nurse include when teaching the parents about the administration of oral penicillin to their child?
- A. Give the medication with a full glass of orange juice.
- B. Give the medication after a large meal.
- C. Continue the medication even if the child develops a rash.
- D. Continue the medication for the full course of therapy.
Correct Answer: D
Rationale: Completing the full course of penicillin therapy eradicates the infection and prevents recurrence or resistance, especially for streptococcal infections.
The nurse advises the parents that, to detect possible complications of juvenile rheumatoid arthritis, the child will require which periodic evaluation?
- A. Chest X-rays
- B. Dental examinations
- C. Hearing examinations
- D. Eye examinations
Correct Answer: D
Rationale: JRA can cause uveitis, an eye inflammation that may lead to vision loss if untreated. Periodic eye examinations are essential to detect this complication early.
Calculating from the date of the mother’s last menstrual period,the nurse determines that her newborn’s gestational age is 40 weeks. Which normal findings should the nurse expect when assessing this newborn at birth? Select all that apply.
- A. Hypertonic flexion of all extremities.
- B. Sole creases on the anterior two-thirds of the sole.
- C. Well-defined incurving of the entire ear pinna.
- D. Presence of a prominent clitoris.
- E. Infant is able to support the head momentarily when pulled to a sitting position.
Correct Answer: A,C,E
Rationale: Full-term newborns (40 weeks) exhibit hypertonic flexion well-defined ear pinna incurving and momentary head support. Sole creases over two-thirds indicate ~37 weeks and a prominent clitoris is seen at 30–32 weeks.
Which finding best indicates that a school-age child has acute glomerular nephritis?
- A. Periorbital edema
- B. Excessive urination
- C. Increased appetite
- D. Low blood pressure
Correct Answer: A
Rationale: Periorbital edema is a classic sign of acute glomerular nephritis due to fluid retention from impaired glomerular filtration, reflecting reduced sodium and water excretion.