The nurse is planning care for a low birth weight newborn. Which is an appropriate nursing intervention to promote adequate oxygenation?

Correct Answer: C

Rationale: Maintaining a neutral thermal environment is an appropriate nursing intervention to promote adequate oxygenation in a low birth weight newborn. Newborns, especially those with low birth weight, have limited capacity to regulate their body temperature. Keeping the baby warm helps prevent cold stress, which can lead to increased metabolic demands and oxygen consumption. By maintaining a neutral thermal environment, the newborn's energy can be directed towards growth and development, rather than compensating for temperature fluctuations. This intervention helps optimize oxygenation and overall well-being of the low birth weight newborn. The other options (A, B, D) do not directly address the need for adequate oxygenation in a low birth weight newborn.

Correct Answer: D

Rationale: Postterm newborns are infants born after 42 weeks of gestation. Some common clinical manifestations of postterm newborns include parchment-like, wrinkled skin due to prolonged exposure to amniotic fluid, and long fingernails as a result of intrauterine growth beyond the expected term. Excessive lanugo and absence of scalp hair are not typically seen in postterm newborns. Increased subcutaneous fat may be more common in infants born at term or post-term, but it is not a specific clinical manifestation of postterm newborns. Minimal vernix caseosa is also usually present in postterm newborns.

Correct Answer: B

Rationale: When determining the chief complaint for an adolescent during a health history, the best approach is to directly ask the adolescent, "Why did you come here today?" This allows the nurse to understand the reason for the visit from the adolescent's perspective and helps in identifying the primary concern or reason for seeking medical care. Adolescent patients should be encouraged to express their own concerns and symptoms in their own words, which can help in building trust and promoting open communication between the nurse and the patient. It is important to prioritize the adolescent's input in determining the chief complaint, as it relates to their own health and well-being.

Correct Answer: D

Rationale: In this case, the tenderness, enlargement, and warmth of the child's cervical lymph nodes are likely due to an infection or inflammation that is close to the site. When lymph nodes are palpated and found to be tender, enlarged, and warm, it often indicates that the lymphatic system is responding to an infection or inflammation in the nearby area. The lymph nodes are part of the body's immune system and can become enlarged and tender as they work to fight off the infection. In this scenario, the most likely explanation is an infection or inflammation located near the cervical lymph nodes.

Correct Answer: D

Rationale: The Babinski sign is a reflex response in infants where their big toe moves upward and the other toes fan out when the sole of the foot is stroked. This reflex is normally present in infants up to around 2 years of age. By the age of 2, the nervous system has matured, and the Babinski sign disappears as the child's motor pathways develop and the reflex becomes suppressed. After the age of 2, the presence of the Babinski sign can indicate neurological issues, so its absence beyond this age is considered normal.