What is the most common cause of neonatal jaundice?

Correct Answer: A

Rationale: The most common cause of neonatal jaundice is physiological jaundice, which occurs due to the immature liver's inability to effectively process bilirubin. This type of jaundice is typically benign, appearing after the first 24 hours of life and peaking around days 2-4. It resolves on its own without treatment as the liver matures and can clear bilirubin efficiently. Option B, breastfeeding jaundice, is caused by inadequate milk intake leading to dehydration and reduced bilirubin excretion. This is less common than physiological jaundice and can be addressed by ensuring proper breastfeeding techniques and frequent feeds. Hemolytic disease (option C) results from blood group incompatibility between the mother and baby, leading to increased breakdown of red blood cells and elevated bilirubin levels. This is less common than physiological jaundice but requires monitoring and potential treatment with phototherapy or exchange transfusion. Infection (option D) is not a common cause of neonatal jaundice unless there are specific underlying conditions such as sepsis. In these cases, jaundice would be just one of many symptoms of a more serious issue. Understanding the various causes of neonatal jaundice is crucial for nurses and healthcare professionals caring for newborns. Recognizing the differences between physiological jaundice, breastfeeding jaundice, hemolytic disease, and jaundice due to infection is essential for proper assessment, management, and education of parents to ensure the well-being of newborns.

Correct Answer: A

Rationale: The correct answer is A) Instituting infection control precautions. In a child with acute lymphocytic leukemia, the initial priority is to prevent infection due to the child's compromised immune system. Children with leukemia are at high risk for infection due to their decreased white blood cell count from both the disease process and treatment. Instituting infection control precautions, such as hand hygiene, limiting visitors, and avoiding exposure to sick individuals, is crucial in protecting the child from potential life-threatening infections. Option B) Encouraging adequate intake of iron-rich foods is not the priority in this scenario because iron intake is not the immediate concern for a child with acute lymphocytic leukemia. Option C) Assisting with coping with chronic illness is important but not the initial priority when the child's health is at immediate risk. Option D) Administering medications via IM injections is not the priority as infection control measures take precedence in a child with leukemia. In an educational context, it is essential for nurses to prioritize interventions based on the immediate needs of the patient. Understanding the unique healthcare needs of children with leukemia and recognizing the importance of infection prevention can significantly impact patient outcomes. Nurses must be well-versed in recognizing and addressing priority interventions to provide safe and effective care to pediatric patients with complex medical conditions like acute lymphocytic leukemia.

Correct Answer: D

Rationale: The correct answer is D) 12 months for administering the varicella zoster vaccine to a child. This vaccine is typically given between 12-15 months of age. Option A) At birth is incorrect because the varicella zoster vaccine is not given immediately at birth; it is scheduled later in infancy. Option B) 2 months is incorrect because the varicella zoster vaccine is not typically administered at such a young age. Option C) 6 months is incorrect as the vaccine is not recommended this early; it is usually given after the child turns one year old. Educationally, it is important for nurses and healthcare professionals to be aware of the recommended vaccine schedules for children to provide them with the necessary protection against preventable diseases. Understanding the timing of vaccination administration is crucial to ensure the child's immune system is adequately prepared to fight off infections. By knowing the correct age for specific vaccines, healthcare providers can contribute to the overall health and well-being of children under their care.

Correct Answer: D

Rationale: In the context of an infant with gastroesophageal reflux (GER), the inappropriate nursing diagnosis is D) Altered oral mucous membranes. This is because GER primarily affects the gastrointestinal system, leading to the regurgitation of stomach contents into the esophagus. While infants with GER may experience symptoms like spitting up and irritability, it does not directly impact the oral mucous membranes. Option A) Fluid volume deficit is a relevant nursing diagnosis for an infant with GER due to the potential loss of fluids through frequent regurgitation. Option B) Risk for aspiration is also appropriate as regurgitated stomach contents can be aspirated into the lungs, leading to respiratory complications. Option C) Altered nutrition: less than body requirements is relevant as the regurgitation can impact the infant's ability to adequately intake and retain nutrients. Educationally, understanding the rationale behind each nursing diagnosis is crucial for providing effective care to infants with GER. By differentiating between appropriate and inappropriate diagnoses, nurses can tailor their interventions to address the specific needs of the infant, promoting better outcomes and quality of care.

Correct Answer: C

Rationale: In a term neonate, sole creases being spread over the entire foot (Option C) is the correct answer. This indicates normal foot development and maturation in a newborn. It is essential for the nurse to recognize this as part of the physical assessment to ensure proper growth and development. Option A, stating the creases are absent near the heels, is incorrect as sole creases should be present throughout the sole of the foot in a healthy newborn. Option B, mentioning creases under the heels only, is incorrect as it does not reflect the typical distribution of sole creases in a term neonate. Option D, stating creases are evident only towards the transverse arch, is incorrect as sole creases should extend over the entire foot, not just towards a specific area. Understanding normal neonatal physical assessments, such as sole crease distribution, is crucial for nurses caring for newborns. It helps in early identification of any abnormalities or developmental issues that may require further evaluation or intervention. By knowing what to expect in a healthy newborn, nurses can provide appropriate care and support to promote optimal growth and development.