The school nurse is conducting a class for school-age children on Lyme disease. Which is characteristic of Lyme disease?

Correct Answer: C

Rationale: Lyme disease is caused by a spirochete bacterium called Borrelia burgdorferi, which enters the skin through the bite of an infected deer tick. It is primarily transmitted to humans through the bite of infected black-legged ticks, commonly known as deer ticks. These ticks carry the bacterium in their gut and can transmit it to humans when they feed on blood. Therefore, Lyme disease is characterized by being caused by a spirochete that enters the skin through a tick bite. Option C is the correct answer in this case, as options A, B, and D do not accurately describe the characteristics of Lyme disease.

Correct Answer: A

Rationale: Providing stimulation during feeding is the most appropriate intervention for a 12-month-old infant with failure to thrive. Infants with failure to thrive may have decreased interest in feeding or difficulty with obtaining adequate nutrition. By providing stimulation during feeding, such as making eye contact, talking gently, and playing soft music, the nurse can help increase the infant's interest and engagement in feeding. This can lead to improved feeding outcomes and help the infant receive the necessary nutrition for growth and development.

Correct Answer: C

Rationale: When the nurse notes blanching of the feet in a high-risk newborn with an umbilical catheter in a radiant warmer, the most appropriate nursing action is to wrap the feet loosely in a prewarmed blanket. Blanching indicates poor circulation to the area, which can be a result of cold stress or constriction of blood vessels. By wrapping the feet in a prewarmed blanket, the nurse can help to restore adequate blood flow to the feet and improve circulation. This action addresses the potential cause of the blanching and promotes the newborn's comfort and well-being.

Correct Answer: D

Rationale: The blood sample for measurement of bilirubin should be drawn when the newborn has been off phototherapy for 30 to 60 minutes. The reason for this is that phototherapy can alter bilirubin levels through photoisomerization, making it challenging to interpret the results accurately while the newborn is still under the lights. Allowing a period of 30 to 60 minutes for the newborn to be off phototherapy helps to ensure that the bilirubin level obtained from the blood sample reflects a more accurate baseline level. This practice helps in guiding clinical management decisions related to managing hyperbilirubinemia in newborns.

Correct Answer: D

Rationale: Neonatal sepsis is a serious condition in newborns that is challenging to diagnose due to nonspecific and variable clinical signs. Some of the common manifestations of neonatal sepsis include poor feeding, lethargy, unstable temperature (hypothermia or hyperthermia), respiratory distress, apnea, irritability, and jaundice. The presence of hypothermia is often noted in neonatal sepsis, but it is essential to keep in mind that clinical signs can be subtle and nonspecific in these cases. Seizures, sudden hyperthermia, profuse sweating, decreased urinary output, and frequent stools are less specific to neonatal sepsis and may be seen in other conditions as well. Regular monitoring, prompt evaluation, and appropriate treatment are crucial in managing neonatal sepsis due to the nonspecific nature of its clinical presentation.