Nokea
The parents of a 5-month-old infant state that their infant seems to eat very little. Most of the food comes out of the infant's mouth and onto his clothes.
- A. "Give the baby a bottle of formula before solid food to assure adequate caloric intake."'
- B. "Stop the solid foods and try again when the baby is 12 months old."'
- C. "Put the cereal in a bottle and feed the baby through a nipple with a large hole."'
- D. "Place the food in the back of the baby's mouth using a long-handled spoon."'
Correct Answer: D
Rationale: The correct answer is D because at 5 months, infants are typically ready to start experimenting with solid foods. Placing the food in the back of the baby's mouth using a long-handled spoon helps prevent the baby from pushing the food out with their tongue reflex, allowing for more successful feeding. This method also encourages the baby to learn how to swallow solids properly. Choice A is incorrect as giving formula before solid food won't address the feeding issue. Choice B is incorrect as stopping solid foods until 12 months can hinder the baby's developmental milestones. Choice C is incorrect as feeding cereal in a bottle can increase the risk of choking and doesn't address the underlying issue of feeding difficulty.
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A nurse has reinforced teaching to the parent of a 9-month-old infant who has redness in the diaper area and inner thighs. Which of the following statements by the parent indicates a correct understanding of this teaching?
- A. I can use a hair dryer on the reddened skin to help with the drying.
- B. I can use powder after diaper changes to absorb excess moisture.
- C. I can use cloth diapers with rubber outer pants until the rash clears.
- D. I can keep the diaper off to expose the skin to air.
Correct Answer: D
Rationale: Exposing the skin to air helps prevent irritation and promotes healing.
A nurse is assessing a client who is at 30 wks gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. Facial swelling in a pregnant woman at 30 weeks gestation could be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. It is important to report this finding promptly to the provider for further evaluation and management to prevent complications for both the mother and the baby. Varicose veins in the calves (B) and hyperpigmentation (D) are common in pregnancy but are not urgent issues requiring immediate reporting. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy but is not as concerning as facial swelling. Make sure to report any change in the severity of edema.
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response?
- A. The purpose of the NST is to assess the fetal CNS.
- B. The purpose of the NST helps to determine gestational age.
- C. The purpose of the NST is to determine fetal lie.
- D. The purpose of the NST is to determine fetal breathing.
Correct Answer: A
Rationale: The correct answer is A: The purpose of the NST is to assess the fetal CNS. The nonstress test (NST) evaluates the fetal CNS by measuring the fetal heart rate in response to fetal movement. This test assesses the overall well-being of the fetus by monitoring for accelerations in the heart rate, indicating a healthy CNS. Choices B, C, and D are incorrect because the NST is not used to determine gestational age, fetal lie, or fetal breathing. The primary focus of the NST is to evaluate the fetal CNS function through monitoring the fetal heart rate patterns.
Which of the following physical manifestations of a client with anorexia nervosa best indicates compliance with the treatment plan of care?
- A. "A weekly weight gain of 1 kg (2.2 lb)"'
- B. "Daily bowel movements that are soft"'
- C. "Return of regular menstrual periods"'
- D. "Improvement of the oral mucosa"'
Correct Answer: A
Rationale: The correct answer is A: "A weekly weight gain of 1 kg (2.2 lb)". In anorexia nervosa, weight restoration is a key goal of treatment to address malnutrition and restore physiological functioning. A weekly weight gain of 1 kg indicates the client is consuming adequate nutrition and their body is responding appropriately to treatment. This physical manifestation suggests the client is compliant with the treatment plan.
Choice B, daily bowel movements that are soft, is not necessarily a direct indicator of compliance with the treatment plan for anorexia nervosa. While bowel movements can be influenced by dietary changes, they are not as specific or reliable as weight gain in assessing treatment compliance.
Choice C, return of regular menstrual periods, is a potential physical manifestation of improved health in anorexia nervosa, but it may not be the best indicator of compliance with the treatment plan, as it can be influenced by various factors.
Choice D, improvement of the oral mucosa, is important for
A nurse is caring for a child with acute glomerulonephritis. The child has edema, hypertension, and gross hematuria. Which of the following is the most appropriate nursing intervention?
- A. Monitor the oxygen saturation every 4 hr.
- B. Teach the parents dietary restrictions regarding protein.
- C. Weigh the child daily and record intake and output.
- D. Counsel the parents about the need for follow-up.
Correct Answer: C
Rationale: The correct answer is C: Weigh the child daily and record intake and output. This intervention is crucial in monitoring fluid balance and kidney function in a child with acute glomerulonephritis. Daily weights help assess for fluid retention, while intake and output measurements help evaluate kidney function. Edema, hypertension, and gross hematuria are key symptoms of this condition, indicating the need for close monitoring.
Choice A is incorrect because monitoring oxygen saturation is not directly related to the management of acute glomerulonephritis. Choice B is also incorrect as dietary restrictions regarding protein are not the priority in this situation. Choice D is incorrect as counseling about follow-up is important but not the most immediate intervention needed.