A nurse is caring for a newborn with jaundice undergoing phototherapy. What intervention is appropriate when caring for the newborn?

Correct Answer: A

Rationale: In caring for a newborn with jaundice undergoing phototherapy, it is crucial to shield the newborn's eyes. This is the correct intervention because phototherapy exposes the newborn's skin to light, which can be harmful to the eyes and increase the risk of eye damage. By covering the newborn's eyes, the nurse helps protect them from potential harm. Option B, covering the genitals, is not necessary in this scenario as the focus of care during phototherapy for jaundice is primarily on the eyes and skin, not the genitals. Option C, encouraging frequent feedings, is a good general nursing intervention for newborns but is not directly related to the specific care needed for a newborn undergoing phototherapy for jaundice. Option D, monitoring for green stools, is not directly related to the care of a newborn undergoing phototherapy for jaundice. The presence of green stools may indicate other issues but is not a priority concern in this context. In an educational context, it is important for nurses to understand the specific interventions required when caring for newborns undergoing phototherapy for jaundice to ensure their safety and well-being. Understanding the rationale behind each intervention helps nurses provide effective and evidence-based care to these vulnerable patients.

Correct Answer: C

Rationale: The correct answer is C) 110 and 160 beats/min. In the immediate post-birth period, it is crucial for the nurse to assess the newborn's vital signs, including heart rate, to ensure the baby is transitioning well to extrauterine life. A healthy, alert neonate typically has a heart rate within the range of 110-160 beats/min. This range is considered normal for a newborn and indicates good cardiovascular function. Option A) 120 and 180 beats/min is too high for a healthy newborn immediately after birth. Such a high heart rate would be concerning and could indicate distress or other underlying issues. Option B) 130 and 170 beats/min is also too high for a newborn's heart rate in the immediate post-birth period. This range is outside the typical normal range for a healthy neonate. Option D) 100 and 130 beats/min is too low for a healthy newborn immediately after birth. A heart rate below 110 beats/min would be considered bradycardia in a neonate and would require immediate attention and intervention. Educationally, understanding the normal vital sign ranges for newborns is essential for nurses working in the neonatal setting. Monitoring and interpreting vital signs accurately can help identify early signs of distress or complications in newborns, allowing for prompt intervention and appropriate care delivery.

Correct Answer: A

Rationale: In this scenario, the nurse should see the 12-month-old child with asthma first (Option A). This choice is based on the child's presenting symptoms of a mild cry, pallor, diminished breath sounds, and low oxygen saturation of 90% on room air. The 12-month-old is at higher risk due to their young age and inability to effectively communicate distress. Pallor and diminished breath sounds indicate a more severe asthma exacerbation requiring immediate attention. The oxygen saturation of 90% is below the normal range, indicating hypoxemia. Option B, the 5-year-old, is speaking in complete sentences, pink in color, and has a higher oxygen saturation of 95%, suggesting a less severe asthma exacerbation. Option C, the 9-year-old, although quiet, has a higher oxygen saturation of 94% and is wheezing bilaterally, indicating less severe distress compared to the 12-month-old. Option D, the 16-year-old, while in a tripod position and wheezing, has a higher oxygen saturation of 93% and is able to speak in short sentences, indicating a less urgent situation compared to the 12-month-old. In an educational context, it is crucial for nurses caring for pediatric patients with asthma to prioritize those at higher risk for respiratory compromise. Understanding the signs and symptoms of respiratory distress in children of different ages is essential for timely and effective intervention to prevent further deterioration.

Correct Answer: B

Rationale: Rationale: The correct answer is B) Providing a low-fat, low carbohydrate diet. In the case of cystic fibrosis (CF), the body has difficulty digesting and absorbing fats. Therefore, a high-fat diet is recommended to help with better absorption of nutrients. A high-protein, high-fat, high-calorie diet (option A) is beneficial for individuals with CF as it helps in meeting their increased energy needs and maintaining a healthy body weight. Option C, providing additional calcium, salt, iron, and zinc in the diet, is also important in managing CF as individuals with this condition may have difficulties absorbing these nutrients due to pancreatic insufficiency. Ensuring adequate intake can help prevent deficiencies. Encouraging exercise (option D) is crucial for individuals with CF as it helps improve lung function, overall physical health, and quality of life. Regular physical activity can help in clearing mucus from the lungs and maintaining cardiovascular health. Option B, providing a low-fat, low-carbohydrate diet, is not appropriate for individuals with CF as they need higher amounts of fat and calories to support their nutritional needs. Restricting fats and carbohydrates can lead to inadequate calorie intake, which is detrimental for individuals with CF who require extra energy to manage their condition. In an educational context, understanding the specific nutritional needs of individuals with CF is crucial for healthcare professionals and caregivers to provide optimal care and support. By ensuring a well-balanced diet tailored to the individual's needs, along with appropriate exercise and nutrient supplementation, the overall health and well-being of individuals with CF can be better managed.

Correct Answer: B

Rationale: In pediatric patients with congestive heart failure, the first-line treatment is typically diuretics (Option B). The rationale behind this is that diuretics help reduce fluid overload and relieve symptoms of congestion by increasing urine output. This helps decrease the workload on the heart and improve overall cardiac function. Antibiotics (Option A) are not the first-line treatment for congestive heart failure unless there is an underlying bacterial infection. Antivirals (Option C) are used to treat viral infections and are not indicated for heart failure. Steroids (Option D) may be used in certain cases of heart failure with inflammation, but they are not the primary treatment for relieving congestion and improving cardiac function. In an educational context, it is crucial for nursing students to understand the appropriate pharmacological interventions for pediatric patients with congestive heart failure. By learning the rationale behind using diuretics as the first-line treatment, students can provide safe and effective care to children with heart failure, optimize patient outcomes, and prevent complications associated with untreated congestion.