The nurse is caring for a preterm newborn who requires mechanical ventilation for the treatment of respiratory distress syndrome. What is the preterm newborn at increased risk of due to the mechanical ventilation?

Correct Answer: A

Rationale: Preterm newborns who require mechanical ventilation are at increased risk of developing alveolar rupture. The pressure from mechanical ventilation can lead to overdistension of the alveoli, causing damage to their delicate structure. This can result in the rupture of the alveolar walls, leading to a condition known as pulmonary interstitial emphysema. Alveolar rupture can contribute to the development of other complications such as pneumothorax and air leaks, which can further compromise the newborn's respiratory status. Therefore, close monitoring and adjustment of ventilation parameters are crucial in the care of preterm newborns on mechanical ventilation to minimize the risk of alveolar rupture and its associated complications.

Correct Answer: C

Rationale: The nurse should describe all details related to the chief complaint under the "Present illness" section of the health history. This section focuses specifically on the patient's current health problem, including the onset, duration, severity, aggravating or alleviating factors, and associated symptoms. It provides a comprehensive understanding of the chief complaint and helps guide further assessment and treatment interventions. The "Chief complaint" section typically contains a concise statement from the patient regarding the main reason for seeking healthcare.

Correct Answer: C

Rationale: Significant head lag in an 8-month-old infant can be a concerning sign indicating potential developmental delays or muscle weakness. The most appropriate action for the nurse in this situation is to refer the child for further evaluation by a healthcare provider, such as a pediatrician or developmental specialist, to assess and address the underlying cause of the head lag. It is important to rule out any potential developmental issues early on to provide the necessary interventions and support for the infant's optimal growth and development.

Correct Answer: B

Rationale: The nurse is testing the girl's cerebellar function by asking her to do the "finger-to-nose" test. The cerebellum is the part of the brain that plays a crucial role in coordinating movement, balance, and posture. In the finger-to-nose test, the child is asked to touch her own nose and then the nurse's finger repeatedly. A properly functioning cerebellum helps control and coordinate these precise movements. If there are issues with the cerebellar function, the child might have difficulty performing this task accurately, indicating a potential problem with motor coordination and balance.

Correct Answer: A

Rationale: At 12 months of age, children are generally starting to become more mobile and interested in exploring their surroundings. Large push-pull toys are a great option for encouraging physical activity and helping with gross motor skills development. These toys can help the child practice walking, crawling, and hand-eye coordination. Push-pull toys also provide kinetic stimulation which is important for the child's overall physical development at this age. Other play activities mentioned in the options, such as finger paints or cradle gym, may be suitable for older children as they require more fine motor skills and coordination. Stick horse, on the other hand, is more appropriate for older children who have better developed gross motor coordination.