Nokea
What formula and/or diet should the nurse suggest?
- A. Lifelong high-protein diet
- B. A formula that is low in the amino acid leucine
- C. A soy-based formula
- D. Substitute Lofenalac for some protein foods
Correct Answer: D
Rationale: Lofenalac, a synthetic food low in phenylalanine, is substituted for natural protein foods to support growth in infants with phenylketonuria.
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What will the nurse instruct the parents to report immediately?
- A. Facial paralysis
- B. Ear infections
- C. Increased intracranial pressure (ICP)
- D. Drooling
Correct Answer: B
Rationale: Children with cleft palate are at risk for ear infections; parents should report signs of earache immediately to the healthcare provider.
What scenario indicates this patient will require RhoGAM administration?
- A. She has had one Rh-negative child and is pregnant with an Rh-negative child.
- B. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus.
- C. She has had an O-negative child and is pregnant with a B-negative child.
- D. She is a primipara with an O-negative child.
Correct Answer: B
Rationale: An Rh-negative mother who has had an Rh-positive child and is pregnant with another Rh-positive fetus requires RhoGAM to prevent antibody formation.
What should they be instructed to provide special attention to in regard to the generalized hypotonicity of the child?
- A. Preventing hyperthermia
- B. Respiratory care
- C. Prevention of diarrhea
- D. Incontinence care
Correct Answer: B
Rationale: Generalized hypotonicity in Down syndrome causes mucus accumulation, increasing the risk of respiratory problems.
When bathing an infant, what sign does the nurse recognize as a sign of developmental hip dysplasia?
- A. Hypotonicity of the leg muscles
- B. One leg is shorter than the other
- C. Broadening and flattening of the buttocks
- D. Two skinfolds on the back of each thigh
Correct Answer: B
Rationale: A shorter leg on the affected side is a sign of developmental hip dysplasia due to the femur slipping out of the acetabulum.
What nursing action is the most appropriate?
- A. Feed solid foods with the spoon at the side of the mouth.
- B. Puree foods and offer them through a straw.
- C. Place small bites of food in the mouth with a tongue blade.
- D. Offer small, frequent meals of finger foods.
Correct Answer: A
Rationale: Feeding with the side of a spoon at the side of the mouth protects the operative site of a cleft palate repair.