The parents of a newborn ask the nurse what caused the baby's facial nerve paralysis. What knowledge should the nurse's response be based on?

Correct Answer: B

Rationale: Facial nerve paralysis in a newborn is most commonly caused by birth injury. This can occur during the birthing process due to pressure on the baby's face or head, particularly if forceps or vacuum extraction are used during delivery. The trauma can affect the facial nerve resulting in temporary or permanent paralysis. It is important for the nurse to provide reassurance to the parents that birth injury is a common cause of facial nerve paralysis in newborns, and in many cases, the paralysis resolves on its own over time without further complications.

Correct Answer: D

Rationale: The presentation of a preterm newborn with difficulty breathing, grunting, tachypnea, and nasal flaring is concerning and should not be considered a normal finding. This could indicate respiratory distress, which is common in preterm infants due to immature lung development. It is important for the nurse to recognize these symptoms as they may signify a potential underlying respiratory issue that requires further evaluation and intervention. Prompt assessment and management are crucial in ensuring the best outcomes for the newborn. Therefore, further evaluation by the healthcare team is warranted in this situation to determine the cause of the respiratory distress and provide appropriate treatment.

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.