Nokea
The provider is educating the parents of a newborn about circumcision care. Which of the following instructions should be included?
- A. Cleanse the penis with each diaper change using alcohol wipes.
- B. Avoid using petroleum jelly on the circumcision site.
- C. Report any yellowish exudate around the head of the penis.
- D. Use warm water to clean the penis gently during diaper changes.
Correct Answer: D
Rationale: The correct instruction for circumcision care is to use warm water to gently clean the penis during diaper changes. Alcohol wipes should be avoided as they can cause irritation. Yellowish exudate around the head of the penis is a normal part of the healing process and does not require reporting unless accompanied by other concerning symptoms. Avoiding petroleum jelly on the circumcision site is important to prevent trapping moisture and bacteria, which can lead to infection.
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The healthcare provider assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The healthcare provider documents this finding to be which of the following?
- A. A normal position
- B. A possible chromosomal abnormality
- C. Facial paralysis
- D. Prematurity
Correct Answer: A
Rationale: When the top of the ear (pinna) is parallel to the outer and inner canthus of the eye, it is considered a normal position in a newborn. This alignment is an important assessment to ensure normal development and anatomy. Choices B, C, and D are incorrect because the parallel alignment of the ears to the outer and inner canthus of the eye is not indicative of a possible chromosomal abnormality, facial paralysis, or prematurity. It is simply a normal anatomical finding in a newborn.
Which pain assessment tool is most appropriate for a 3-month-old hospitalized with a fractured femur?
- A. FLACC scale
- B. Poker chip tool
- C. Number scale
- D. Visual analog scale
Correct Answer: A
Rationale: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is specifically designed for nonverbal patients like infants and young children. It assesses pain based on observable behaviors such as facial expressions, leg movement, activity level, cry, and the ability to be consoled. In this case, a 3-month-old infant who is unable to communicate verbally would best be assessed using the FLACC scale to determine the level of pain experienced due to a fractured femur. The Poker chip tool, Number scale, and Visual analog scale are not suitable for nonverbal infants and young children as they rely on self-reporting or cognitive abilities that are not yet developed at this age.
A postpartum client is concerned about hair loss. The nurse explains that this is:
- A. A sign of nutritional deficiency
- B. A temporary condition due to hormonal changes
- C. An indication of a thyroid disorder
- D. A result of poor hair care during pregnancy
Correct Answer: B
Rationale: Hair loss postpartum is a common temporary condition caused by hormonal changes that occur after giving birth. This condition is known as postpartum alopecia and is a normal part of the postpartum period. It is important for the nurse to reassure the client that this hair loss is temporary and usually resolves on its own without the need for medical intervention. Choice A is incorrect because postpartum hair loss is primarily due to hormonal changes rather than nutritional deficiency. Choice C is incorrect as thyroid disorder is not typically the cause of postpartum hair loss. Choice D is incorrect as poor hair care during pregnancy does not cause postpartum hair loss.
An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?
- A. High risk for altered body temperature - hyperthermia
- B. Ineffective breathing pattern
- C. Ineffective individual coping
- D. Knowledge deficit
Correct Answer: B
Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.
In educating the parents of a child diagnosed with hypothyroidism, the nurse mentions that the child should avoid goitrogens. Which of the following will the nurse mention as an example?
- A. Orange
- B. Tomatoes
- C. Cabbage
- D. Grapes
Correct Answer: C
Rationale: Cabbage is an example of a goitrogen that should be avoided in children with hypothyroidism. Goitrogens are substances that can interfere with thyroid function by inhibiting iodine uptake, potentially worsening the condition. Cabbage, along with other cruciferous vegetables like broccoli and cauliflower, contains compounds that can affect thyroid hormone production. Oranges, tomatoes, and grapes are not classified as goitrogens. Therefore, it is important for parents to be aware of foods like cabbage and to limit their child's intake to help manage their hypothyroidism effectively.