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Which dietary recommendation should the nurse provide to the parents of a child with iron deficiency anemia?
- A. Increase intake of red meat and leafy greens.
- B. Offer more dairy products like milk and cheese.
- C. Provide high-sugar snacks to boost energy.
- D. Limit consumption of whole grains.
Correct Answer: A
Rationale: Red meat and leafy greens are rich in iron, which is essential for correcting iron deficiency anemia by boosting hemoglobin production.
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The nurse finds documentation in the 4-hour-old newborn’s medical record that states,“Clamping of the umbilical cord was delayed until cord pulsations ceased.” When assessing and collecting additional information about the newborn,what effect should the nurse find as a result of the delayed cord clamping?
- A. More rapid expulsion of meconium by the newborn
- B. Increased level of newborn alertness after birth
- C. An increase in the newborn’s initial temperature
- D. An increase in the newborn’s hemoglobin and hematocrit
Correct Answer: D
Rationale: Newborn Hgb and Hct values will be higher when placental transfusion accomplished through delayed cord clamping occurs at birth. Blood volume increases by up to 50% with delayed cord clamping. Meconium passage alertness and temperature are not affected by delayed clamping.
The nurse is caring for a preterm infant who must be fed via bolus gavage feeding. The infant has a 5 French feeding tube already secured in the left naris. The nurse has aspirated the infant’s stomach contents, noting color, amount, and consistency, and has reinserted the residual amount because it was less than one-fourth the previous feeding. Prioritize the remaining steps that the nurse should take to complete this feeding.
- A. Elevate the syringe 6 to 8 inches over the infant’s head.
- B. Position the infant on the right side.
- C. Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate.
- D. Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel.
- E. Cap the lavage feeding tube.
Correct Answer: D, A, F, C, E, B, G
Rationale: Sequence: Position infant on right side (D) to reduce aspiration risk connect syringe barrel (A) crimp tube and pour formula (F) elevate syringe (C) uncrimp for gravity flow (E) clear tubing with air (B) cap tube (G).
Which intervention is most appropriate initially for an 8-year-old child who selects the fourth face on the Wong-Baker FACES Pain Rating Scale?
- A. Take no action; the child is pain-free.
- B. Provide diversional activities to relieve the child's pain.
- C. Document findings, and recheck the child later.
- D. Give the prescribed analgesic to relieve the pain.
Correct Answer: D
Rationale: The fourth face on the Wong-Baker FACES Pain Rating Scale indicates moderate to severe pain, requiring administration of a prescribed analgesic for effective pain relief.
Which of the following findings during a routine wellness checkup best indicates that a child has iron deficiency anemia?
- A. Weight gain and hypertension
- B. Nervousness and diarrhea
- C. Nausea and vomiting
- D. Pallor and listlessness
Correct Answer: D
Rationale: Pallor and listlessness are hallmark signs of iron deficiency anemia due to reduced hemoglobin, leading to decreased oxygen delivery and fatigue.
The full-term newborn is placed under phototherapy lights to treat hyperbilirubinemia. The nurse should assess the newborn for dehydration due to which effect of phototherapy?
- A. Decreases sodium absorption
- B. Increases absorption of bilirubin
- C. Decreases urinary output
- D. Increases insensible water loss
Correct Answer: D
Rationale: Phototherapy increases insensible water loss risking dehydration. It breaks down bilirubin for excretion not absorption and doesn’t directly affect sodium or urinary output.