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What would the nurse include when instructing parents about positioning their toddler who has just had a body spica cast applied?
- A. Prop the child upright with pillows for meals.
- B. Use the bar between the legs to turn the child.
- C. Put the child on her abdomen to sleep.
- D. Change the child's position frequently.
Correct Answer: D
Rationale: Frequent position changes relieve pressure and promote circulation in a toddler with a body spica cast.
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What characteristics are typical in a child diagnosed with Down syndrome?
- A. Close-set eyes
- B. Simian creases
- C. Wide-spaced front teeth
- D. Protruding tongue
- E. Curved, small fingers
Correct Answer: A,B,D,E
Rationale: Children with Down syndrome have close-set upturned eyes, simian creases, protruding tongue, and curved, small fingers.
The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a mother who took opioids during pregnancyWhat would be the manifestations of this syndrome?
- A. Body tremors
- B. Excessive sneezing
- C. Hyperirritability
- D. Drowsiness
- E. Excessive appetite
Correct Answer: A,B,C
Rationale: Neonatal abstinence syndrome manifests as tremors, hyperirritability, and excessive sneezing due to opioid withdrawal.
The nurse explains that what is the optimal time for testing for phenylketonuria?
- A. In the first 24 hours of life
- B. After 2 to 3 days
- C. At 4 to 6 weeks of age
- D. At 2 months of age
Correct Answer: B
Rationale: Testing for phenylketonuria at 48 to 72 hours allows sufficient protein intake to reduce false-negative results.
The home health nurse is educating parents on home phototherapy. What will the nurse include when providing information to these parents?
- A. Cover the infant's eyes when under the light.
- B. Use a three-prong plug.
- C. Keep a diaper in place.
- D. Place the light source on an absorbent surface.
- E. Expose as much skin as possible.
Correct Answer: B,C,E
Rationale: Home phototherapy instructions include using a three-prong plug, keeping a diaper in place, and exposing as much skin as possible; the light source should be on a nonabsorbent surface, and eyes do not need covering.
What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of?
- A. High-pitched cry
- B. Unequal pupils
- C. Bulging fontanelles
- D. Diarrhea
- E. Hiccups
Correct Answer: A,B,C
Rationale: Increased intracranial pressure is indicated by a high-pitched cry, unequal pupils, and bulging fontanelles in a hydrocephalic child.