The nurse is planning care for a newborn receiving IV calcium gluconate for treatment of hypocalcemia. Which intervention is the most appropriate during the acute phase?

Correct Answer: D

Rationale: During the acute phase of treatment with IV calcium gluconate for hypocalcemia in a newborn, it is essential to closely monitor the newborn's level of consciousness. Hypocalcemia can lead to central nervous system changes, such as irritability, jitteriness, and seizures. By awakening the newborn periodically to assess their level of consciousness, the nurse can promptly identify any signs of worsening central nervous system involvement and take appropriate action. This intervention ensures timely detection of any neurological complications and allows for timely intervention to prevent serious consequences. The other options do not address the importance of monitoring for central nervous system changes during the acute phase of treatment for hypocalcemia.

Correct Answer: B

Rationale: Using a simple magic trick with gauze to engage a 5-year-old child during a dressing change is a way to establish rapport. This approach can help build trust and reduce anxiety by making the procedure more engaging and less intimidating for the child. By creating a positive interaction through a fun activity, the nurse can promote cooperation and make the dressing change a smoother experience for the child. Overall, the use of a magic trick in this context is appropriate and beneficial for enhancing the child's cooperation and comfort.

Correct Answer: C

Rationale: Petechiae are small, pinpoint, red or purple spots on the skin caused by bleeding into the skin. In dark-skinned individuals, it can be challenging to visualize petechiae due to the pigmentation of the skin. However, one of the best places to observe for the presence of petechiae in dark-skinned individuals is the oral mucosa, specifically the inner lining of the mouth. The oral mucosa is usually lighter in color compared to the skin, making it easier to identify petechiae in this area. Palms and soles may also be a good place to observe for petechiae, but the oral mucosa is typically the preferred site for examination in dark-skinned individuals.

Correct Answer: A

Rationale: The "tailor" position, also known as the frog-leg position, is used during palpation for the testes in young boys because it helps prevent the cremasteric reflex. The cremasteric reflex is a normal reflex in which the testes are pulled upwards towards the inguinal canal when the inner thigh is stroked. By having the child sit in the tailor position, with the knees pulled up and legs rotated outwards, the reflex is less likely to be elicited, allowing for a more accurate examination of the testes.

Correct Answer: C

Rationale: Object permanence is the understanding that objects continue to exist even when they can't be seen, heard, or touched. When an infant actively searches for a hidden object, it demonstrates that the infant has developed object permanence. This behavior implies that the infant understands that the object still exists even though it is temporarily out of sight. This usually emerges around 8-12 months of age, according to Piaget's theory of cognitive development. The other choices do not specifically relate to the concept of object permanence as directly as actively searching for a hidden object does.