A nurse is assessing a child with kwashiorkor disease. Which assessment findings should the nurse expect?

Correct Answer: A

Rationale: Kwashiorkor is a form of severe acute malnutrition characterized by a deficiency in protein intake, leading to a protein-energy malnutrition. One of the hallmark signs of kwashiorkor is an enlarged, protruding abdomen due to fluid retention in the tissues (edema), giving the appearance of a swollen belly. Additionally, individuals with kwashiorkor often have thin, wasted extremities while their abdomen appears disproportionately distended. This is known as the "big belly, skinny limbs" presentation, which arises due to the imbalance of protein and energy intake. Therefore, the nurse assessing a child with kwashiorkor should expect to find thin wasted extremities with a prominent abdomen.

Correct Answer: C

Rationale: When the nurse notes blanching of the feet in a high-risk newborn with an umbilical catheter in a radiant warmer, the most appropriate nursing action is to wrap the feet loosely in a prewarmed blanket. Blanching indicates poor circulation to the area, which can be a result of cold stress or constriction of blood vessels. By wrapping the feet in a prewarmed blanket, the nurse can help to restore adequate blood flow to the feet and improve circulation. This action addresses the potential cause of the blanching and promotes the newborn's comfort and well-being.

Correct Answer: D

Rationale: The blood sample for measurement of bilirubin should be drawn when the newborn has been off phototherapy for 30 to 60 minutes. The reason for this is that phototherapy can alter bilirubin levels through photoisomerization, making it challenging to interpret the results accurately while the newborn is still under the lights. Allowing a period of 30 to 60 minutes for the newborn to be off phototherapy helps to ensure that the bilirubin level obtained from the blood sample reflects a more accurate baseline level. This practice helps in guiding clinical management decisions related to managing hyperbilirubinemia in newborns.

Correct Answer: D

Rationale: Neonatal sepsis is a serious condition in newborns that is challenging to diagnose due to nonspecific and variable clinical signs. Some of the common manifestations of neonatal sepsis include poor feeding, lethargy, unstable temperature (hypothermia or hyperthermia), respiratory distress, apnea, irritability, and jaundice. The presence of hypothermia is often noted in neonatal sepsis, but it is essential to keep in mind that clinical signs can be subtle and nonspecific in these cases. Seizures, sudden hyperthermia, profuse sweating, decreased urinary output, and frequent stools are less specific to neonatal sepsis and may be seen in other conditions as well. Regular monitoring, prompt evaluation, and appropriate treatment are crucial in managing neonatal sepsis due to the nonspecific nature of its clinical presentation.

Correct Answer: C

Rationale: When interviewing children and their families, nurses should avoid directing the focus. Directing the focus involves steering the conversation in a certain direction, which may hinder open communication and the exploration of important issues. It is essential to allow children and their families to express themselves freely and openly, which can lead to a more comprehensive understanding of their perspectives and needs. Avoiding directing the focus can help build trust and rapport with the children and their families, leading to more effective communication and care.