Nokea
Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner?
- A. Infant refuses a feeding.
- B. Infant has an axillary temperature of 97?°F.
- C. Infant has three pasty, yellow-brown stools in 24 hours.
- D. Infant's diaper is not wet after 8 hours.
Correct Answer: D
Rationale: Decreased or lack of voiding by the newborn should be reported to prevent dehydration.
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What symptom assessed in the newborn shortly after delivery should be reported?
- A. Cyanosis of the hands and feet
- B. Irregular heart rate
- C. Mucus draining from the nose
- D. Sternal or chest retractions
Correct Answer: D
Rationale: Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.
What is the most appropriate nursing response to this mother?
- A. Tell me how many hours per day your baby sleeps.'
- B. It is normal for newborns to sleep most of the day.'
- C. Newborns generally sleep 12 to 15 hours per day.'
- D. You will find as the baby gets older, he sleeps less.'
Correct Answer: A
Rationale: The nurse should first clarify what the mother means by 'too much' sleep to provide accurate information and address concerns.
What information will the nurse provide when educating this patient on alendronate (Fosamax)?
- A. Drink 8 oz. of water following dosage.
- B. Lay down for 30 minutes after taking.
- C. This medication has no known side effects.
- D. Avoid weight-bearing exercises.
Correct Answer: A
Rationale: Alendronate (Fosamax) may cause esophageal and gastric irritation. The patient should drink 8 ounces of plain water and sit upright for 30 minutes after taking the drug and before eating. Weight-bearing exercises are advisable, and high-impact exercises should be avoided.
What is the nurse's most helpful response when instructing the parents?
- A. Contact a pediatric dermatologist for topical medication.
- B. Squeeze out the white material after cleansing the face.
- C. Wash the infant's face with a mild astringent several times a day.
- D. Leave the milia alone; it will disappear spontaneously. No treatment is needed.
Correct Answer: D
Rationale: Milia require no treatment and will disappear spontaneously.
What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn?
- A. Depressed and sunken
- B. Triangular shaped
- C. Smaller than the posterior fontanelle
- D. Open and diamond shaped
Correct Answer: D
Rationale: The anterior fontanelle is diamond shaped, located at the junction of the two parietal and two frontal bones, and should not be raised or sunken. It closes between 12 and 18 months.