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When developing the plan of care for a neonate who was diagnosed with an anorectal malformation and who subsequently underwent surgery, which of the following would be most helpful in facilitating parent-infant bonding?
- A. Explaining to the parents that they can visit at any time.
- B. Encouraging the parents to hold their infant.
- C. Asking the parents to help monitor the infant's intake and output.
- D. Helping the parents plan for their infant's discharge.
Correct Answer: B
Rationale: Physical contact through holding fosters bonding and emotional connection.
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Which of the following client actions should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy?
- A. Insisting on wearing a T-shirt and gym shorts rather than pajamas.
- B. Avoiding interactions with other adolescents on the nursing unit.
- C. Refusing to fill out the menu, and allowing the nurse to do so.
- D. Not taking telephone calls from friends so he can rest.
Correct Answer: A
Rationale: Choosing preferred clothing reflects autonomy and positive coping.
A newborn who had a surgical repair of a tracheoesophageal fistula (TEF) is started on oral feedings. Which of the following should the nurse include in the teaching plan for the mother about oral feedings?
- A. They are better tolerated when larger, but less frequent feedings are offered.
- B. They should be offered on a feeding schedule to help the infant accept the feedings more readily.
- C. They are best accepted by the infant when offered by the same nurse or by the infant's mother.
- D. They are best planned in conjunction with observations of the infant's behavior.
Correct Answer: D
Rationale: Observing the infant's behavior ensures feedings align with hunger cues, promoting tolerance.
The health care provider has ordered a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family:
- A. I will request an order for a sedative to help him relax.
- B. I can't do anything to reduce the pain
- C. but you can hold him during the procedure.
- D. I will get an order for a lidocaine-based lubricant to make the procedure more comfortable.
- E. I can apply a topical anesthetic 20 minutes before placing the catheter.
Correct Answer: D
Rationale: Topical anesthetics can minimize discomfort.
When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, which of the following descriptions about the stoma's appearance should the nurse include in the teaching?
- A. Becoming dark brown in 2 months.
- B. Appearing moist and pink to red.
- C. Drying out within a few weeks.
- D. Shrinking significantly in size.
Correct Answer: B
Rationale: A healthy stoma is moist and pink to red, indicating good blood supply.
An 8-year-old has a body mass index (BMI) for age at the 90th percentile, but has no other risk factors. The nurse should:
- A. Refer for a weight management program.
- B. Prescribe a low-calorie diet.
- C. Order fasting glucose levels.
- D. Initiate daily exercise logs.
Correct Answer: A
Rationale: A BMI at the 90th percentile indicates overweight. A weight management program promotes healthy habits. Diet prescription, glucose testing, or exercise logs are premature without further risk assessment.