What is an early clinical manifestation of bilirubin encephalopathy in the newborn?

Correct Answer: C

Rationale: An early clinical manifestation of bilirubin encephalopathy in a newborn is lethargy or irritability. Bilirubin encephalopathy, also known as kernicterus, is a serious condition that occurs when high levels of unconjugated bilirubin build up in the brain tissues. Initially, the baby may become lethargic or irritable due to the toxic effects of bilirubin on the central nervous system. As the condition progresses, symptoms may include poor feeding, high-pitched crying, muscle tone abnormalities, and eventually may lead to more severe consequences such as seizures and irreversible neurological damage. Prompt recognition and treatment of bilirubin encephalopathy are crucial to prevent long-term complications.

Correct Answer: A

Rationale: When meeting a new patient and their family for the first time, it is important for the nurse to first introduce themselves. This establishes a professional relationship and helps to build trust. By introducing themselves, the nurse demonstrates respect and initiates communication with the adolescent and their parents. It also sets a positive tone for the interaction and creates a welcoming environment for further discussion. The introduction should include the nurse's name, role, and purpose of the visit.

Correct Answer: D

Rationale: Upper arm circumference has been found to correlate best with measurements of the body's total protein stores. This anthropometric measurement is often used as an indicator of nutritional status, particularly protein reserves such as muscle mass. Skinfold thickness can provide information about body fat levels, while height and weight may not specifically indicate protein stores as accurately as upper arm circumference.

Correct Answer: C

Rationale: The HOTV chart is the most appropriate vision acuity test for a child who is in preschool. The HOTV chart is specifically designed for young children who may not yet know their letters. It uses simple shapes (H, O, T, V) instead of letters for visual acuity testing, making it more suitable and engaging for preschool-aged children. This chart allows for an accurate assessment of a child's visual acuity even before they are able to recognize letters, ensuring early detection of any vision problems that may affect their learning and development. The other options, such as the Cover test, Ishihara test, and Snellen letter chart, are more commonly used for older children and adults.

Correct Answer: C

Rationale: The statement that best describes the infant's physical development that a nurse should expect to find is that birth weight doubles by age 5 months and triples by age 1 year. This characteristic growth pattern is typical in the first year of life. Infants usually regain their birth weight by around 2 weeks of age, double it by about 5 months, and triple it by 1 year. This steady growth reflects the healthy development of the infant and is an important marker of overall well-being and nutrition. It is a key aspect that healthcare providers, including nurses, monitor closely to ensure the infant is thriving.