While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?

Correct Answer: B

Rationale: Acrocyanosis is a normal finding in newborns, characterized by bluish discoloration of the hands and feet due to immature circulation. It usually resolves on its own within 24 hours after birth and does not require any intervention. It is essential for the nurse to recognize this normal physiological process to avoid unnecessary interventions. Activating the code blue system, taking the newborn's temperature immediately, or notifying the physician of the need for a cardiac consult is not indicated in this scenario because acrocyanosis is a benign condition in neonates.

Correct Answer: C

Rationale: The best position to keep Sunshine in after a lumbar puncture is in the supine position for several hours. This position helps prevent a post-lumbar puncture headache, which is a common complication of the procedure. Keeping Sunshine supine helps reduce the chances of leaking CSF and minimizes the risk of developing a headache due to decreased CSF pressure. Additionally, it is vital to encourage increased fluid intake post-procedure to help replenish the lost CSF and prevent dehydration.

Correct Answer: B

Rationale: The parachute reflex typically emerges around 9 months of age and is considered a normal reflex in infants. This reflex is characterized by the infant extending their arms to protect themselves when they feel like they are falling. This is an important protective reflex that helps a child develop their sense of balance and coordination. Persistent rooting is not a normal reflex in a 9-month-old baby, as it typically disappears by 4 months of age. The Moro reflex is typically present in infants and involves an outstretched movement of the arms when startled, so its absence would not be considered normal at this age. A unilateral grasp is also not a normal reflex at 9 months, as infants should be able to show coordinated bilateral movements by this age.

Correct Answer: C

Rationale: Cerebral palsy is the most common permanent disability in childhood among the options provided. It is a group of disorders that affect movement and muscle coordination due to damage or abnormal development in the brain. Cerebral palsy can occur before, during, or shortly after birth, and it is a lifelong condition that impacts a child's ability to move, maintain balance, and posture. Scoliosis, muscular dystrophy, and developmental dysplasia of the hip (DDH) are also significant conditions that can lead to disabilities in children, but they are not as prevalent as cerebral palsy in terms of permanent disabilities in childhood.

Correct Answer: B

Rationale: Celiac disease is an autoimmune disorder triggered by gluten, a protein found in wheat, barley, and rye. The small intestine's lining is damaged when someone with celiac disease eats gluten, which impairs the absorption of nutrients. Therefore, it is crucial for individuals with celiac disease to avoid wheat and other gluten-containing grains to manage their condition effectively. Sourcers of gluten, like wheat products, need to be eliminated from the diet to prevent symptoms and complications for those with celiac disease. Therefore, teaching the parents of a child diagnosed with celiac disease to avoid wheat would be an essential part of managing the condition.