The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation. While taking vital signs and changing the newborn's diaper, the nurse observes the newborn's color is pink but slightly mottled, arms and legs are limp and extended, hiccups are present, and heart rate is regular and rapid. The nurse should recognize these behaviors as manifestations of:

Correct Answer: C

Rationale: The behaviors described, such as slightly mottled skin, limp and extended extremities, hiccups, and a rapid but regular heart rate, are typical of preterm newborn behavior. Preterm infants often exhibit these characteristics due to their immature neurological and physiological systems. The mottled skin may be due to the immature vascular system, while the limp and extended extremities are common in preterm newborns as they have less muscle tone compared to full-term infants. Hiccups are also common in newborns, including preterm infants, and are generally not a cause for concern. The rapid heart rate is typical in newborns, particularly in the immediate postnatal period. Therefore, in this scenario, these behaviors are most likely related to the preterm status of the newborn rather than indicating stress, seizures, or respiratory distress.

Correct Answer: B

Rationale: Phenylketonuria (PKU) is a genetic disorder that affects the body's ability to metabolize the amino acid phenylalanine. Individuals with PKU lack an enzyme called phenylalanine hydroxylase, which results in the buildup of phenylalanine in the body. If untreated, high levels of phenylalanine can lead to intellectual disabilities, seizures, and other serious health problems. Therefore, individuals with PKU need to follow a special diet low in phenylalanine to prevent these complications.

Correct Answer: C

Rationale: The most appropriate nursing action when an 8-year-old girl asks how the blood pressure apparatus works is to explain in simple terms how it works. Children are curious by nature and providing a simple explanation in a language they can understand helps satisfy their curiosity and also promotes their understanding. By explaining how the blood pressure apparatus works, the nurse can educate the child about a common medical device and reduce any anxiety or fear the child may have about it. This approach encourages the child to feel more comfortable and engaged in their healthcare experience.

Correct Answer: B

Rationale: A tympanic membrane sensor or tympanic thermometer is the best option for determining the temperature of a preterm infant under a radiant heater. Tympanic thermometers are quick and non-invasive, making them ideal for use in neonatal care. They provide accurate readings by measuring the infrared heat waves coming from the eardrum. This method is preferred over other options like axillary sensors, rectal mercury thermometers, and rectal electronic thermometers, which may not be as efficient or suitable for use with preterm infants.

Correct Answer: C

Rationale: A ventricular septal defect (VSD) is a congenital heart defect characterized by a hole in the septum that separates the heart's two lower chambers (ventricles). When assessing a child with an unrepaired VSD, the nurse would expect to hear a murmur. The murmur is typically described as a harsh, holosystolic (pansystolic) murmur, best heard at the left lower sternal border. This murmur occurs due to the turbulent blood flow across the defect during systole. It is important for the nurse to recognize this characteristic murmur associated with a VSD to facilitate appropriate management and follow-up care for the child.