Nokea
Which information is most appropriate for the nurse to collect at this time?
- A. The infant's weight and length
- B. The infant's breath and heart sounds
- C. The infant's head and chest circumference
- D. The infant's sucking and grasp reflexes
Correct Answer: A
Rationale: Weight and length assess growth and potential failure to thrive, relevant to the mother's concern.
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Which of the following behaviors exhibited by the child demonstrates the most severe reaction to prolonged hospitalization?
- A. Clinging to the parents
- B. Shaking the crib frantically
- C. Thrashing about
- D. Ignoring the parents
Correct Answer: D
Rationale: Ignoring parents indicates severe emotional withdrawal, a significant concern.
To help the parents cope with their disappointment and loss of their 'perfect' baby, which nursing action is most appropriate initially?
- A. Encourage the parents to verbalize their feelings.
- B. Treat the child as a normal newborn.
- C. Refer the couple to community resources for assistance.
- D. Encourage the parents to consider long-term institutional placement.
Correct Answer: A
Rationale: Encouraging verbalization allows parents to express grief and begin processing their emotions, which is critical initially for coping with the diagnosis.
When reviewing the assessment data, the nurse would expect to note which characteristic physical finding?
- A. Extremely low body weight
- B. Erosion of dental enamel
- C. Cessation of menstruation
- D. Patchy loss of hair
Correct Answer: B
Rationale: Erosion of dental enamel is caused by frequent vomiting in bulimia.
The nurse advises the parents of a child taking methylphenidate hydrochloride (Ritalin) that, to avoid potentiating the drug's effects, it is best if their child refrains from consuming which food?
- A. Citrus foods
- B. Cola beverages
- C. Processed meats
- D. Saturated fats
Correct Answer: B
Rationale: Caffeine in cola can enhance Ritalin's stimulant effects.
Which nursing action is most appropriate for the mother at this time?
- A. Briefly take over bathing the newborn.
- B. Advise the mother to discontinue the bath.
- C. Give all future baths in the nursery.
- D. Point out the good job being done.
Correct Answer: A
Rationale: Taking over briefly supports the mother, reducing her anxiety while allowing her to remain involved.