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When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
- A. At birth
- B. During first 24 hours after birth
- C. 24 to 48 hours after birth
- D. 48 to 72 hours after birth
Correct Answer: D
Rationale: In a newborn with hemolytic disease, jaundice typically appears 48 to 72 hours after birth due to the accumulation of bilirubin in the baby's blood. This condition is known as hyperbilirubinemia, which occurs when the liver is still immature and unable to effectively process bilirubin. The breakdown of red blood cells in hemolytic disease leads to an increased production of bilirubin, resulting in jaundice. It is important for healthcare providers to monitor the newborn closely during this time period to ensure appropriate management of the jaundice.
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Which food should be avoided by the patient on a low-sodium diet?
- A. Apples
- B. Chicken
- C. Cheese
- D. Broccoli
Correct Answer: C
Rationale: Cheese is high in sodium and should be avoided by patients on a low-sodium diet. It is a common source of hidden sodium in many diets. Other high-sodium foods that should be limited or avoided include processed meats, canned soups, processed snacks, and condiments. Patients should focus on eating fresh fruits and vegetables, lean proteins like chicken (with no added salt), and whole grains to maintain a low-sodium diet.
In terms of fine motor development, what should the infant of 7 months be able to do?
- A. Transfer objects from one hand to the other and bang cubes on a table.
- B. Use thumb and index finger in crude pincer grasp and release an object at will.
- C. Hold a crayon between the fingers and make a mark on paper.
- D. Release cubes into a cup and build a tower of two blocks.
Correct Answer: A
Rationale: At 7 months old, infants are typically able to transfer objects from one hand to the other and bang cubes on a table. This demonstrates the development of their fine motor skills related to coordination, dexterity, and object manipulation. They are refining their hand-eye coordination and grasping abilities at this stage, preparing for more complex fine motor tasks in the future. The ability to purposefully transfer objects between hands and make intentional actions, like banging cubes on a table, shows the progression of their fine motor development at this age.
An infant has been diagnosed with cow's milk allergy. What are the clinical manifestations the nurse expects to assess? (Select all that apply.)
- A. Pink mucous membranes
- B. Vomiting
- C. Rhinitis
- D. Abdominal pain
Correct Answer: B
Rationale: Pink mucous membranes are not a typical clinical manifestation of cow's milk allergy. Allergies often present with symptoms affecting the gastrointestinal tract, respiratory system, skin, or a combination of these systems.
A nurse is collecting subjective and objective information about target populations to diagnose problems based on community needs. This describes which step in the community nursing process?
- A. Planning
- B. Diagnosis
- C. Assessment
- D. Establishing objectives
Correct Answer: C
Rationale: In the community nursing process, the step of collecting subjective and objective information about target populations to diagnose problems based on community needs is known as "Assessment." This step involves gathering data through observation, interviews, surveys, and other methods to understand the health status, priorities, assets, and resources of the community. This information is essential for identifying the health needs and issues within the community, which then informs the planning and implementation of appropriate interventions. Assessment helps nurses develop a comprehensive understanding of the community's strengths, challenges, and opportunities, enabling them to make informed decisions and tailor interventions to meet the specific needs of the target population.
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
- A. Hematocrit 48%
- B. paCO2 38 mm Hg
- C. platelets 18,000
- D. WBC count 8000
Correct Answer: C
Rationale: A platelet count of 18,000 is significantly low, indicating a condition known as thrombocytopenia, which can lead to a risk of bleeding. In a critical care setting like the ICU, low platelet counts need to be addressed urgently to prevent serious complications such as hemorrhage. This result must be reported immediately to the physician so that appropriate interventions, such as transfusion of platelets, can be initiated promptly to manage the patient's condition effectively. Hematocrit, paCO2, and WBC count may also be important parameters to monitor in an ICU patient, but the critically low platelet count poses the most immediate threat to the patient's well-being and requires urgent attention.