QUESTIONS AND CORRECT ANSWERS
The nurse caring for an 18-month-old infant with Meckel diverticulum knows that the most
common clinical manifestation of this condition is: - CORRECT ANSWER - Painless
rectal bleeding
In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which
intervention? - CORRECT ANSWER - prepare the infant for surgery
The nurse is doing dietary teaching with the caregivers of a child diagnosed with idiopathic
celiac disease. Of the following foods, which would most likely be appropriate in the child's
diet? - CORRECT ANSWER - bananas
The first method of choice for obtaining a urine specimen from a 3-year-old child with a possible
urinary tract infection is: - CORRECT ANSWER - obtaining a clean catch voided urine.
The nurse is caring for a child admitted with acute glomerulonephritis. Which clinical
manifestation would likely have been noted in the child with this diagnosis? - CORRECT
ANSWER - Tea-colored urine
A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-
old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as
opposed to vomiting? - CORRECT ANSWER - Only occurs with feeding
The nurse is caring for a child diagnosed with hydronephrosis. Which manifestation is consistent
with complications of the disorder? - CORRECT ANSWER - Hypertension
The student nurse is preparing a presentation on celiac disease. What information should be
included? Select all apply. - CORRECT ANSWER - "Symptoms of celiac disease include
diarrhea, steatorrhea, anemia, and dental disorders."
"The only treatment for celiac disease is a strict gluten-free diet."
,"Gluten is found in most wheat products, rye, barley and possibly oats."
Which statement is true regarding fetal and newborn senses? - CORRECT ANSWER -
The rooting reflex is an example that the newborn has a sense of touch.
All the options are signs of respiratory distress in the newborn except: - CORRECT
ANSWER - respiratory rate >50 breaths/minute.
Coughing and sneezing are normal reflexes present in newborns. The expected respiratory rate of
newborn is 30 to 60 breaths per minute.
A nurse teaches new parents that the best way to help prevent infections in the newborn is which
method? - CORRECT ANSWER - Breastfed
A major source of IgA, which helps in immunity, is human breast milk.
A nursing student is preparing a class for new mothers about adaptations they can expect in their
newborns. Which information about newborn vision should the student include in the
presentation? - CORRECT ANSWER - Newborns have the ability to focus only on objects
in close proximity.
The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F
(37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss
can be explained in part by which factor in the newborn? - CORRECT ANSWER - lack of
subcutaneous fat
As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing
observation would warrant further investigation? - CORRECT ANSWER - bright red,
raised bumpy area noted above the right eye
A red bumpy area noted above the right eye is a hemangioma and needs further investigation to
determine whether the hemangioma could interfere with the infant's vision.
, The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates
understanding of teaching when she identifies which characteristics as being true of the stool of
breastfed newborns? Select all that apply. - CORRECT ANSWER - yellowish gold color
stringy to pasty consistency
To indicate that the infant is making a successful transition immediately after birth, the nurse
checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause
for concern? - CORRECT ANSWER - 108 bpm
The heart rate of a fetus in utero averages between 110 and 160 beats/minute.
The nurse is caring for a newborn after the parents have spent time bonding. As the nurse
performs the assessment and evidence-based care, which eye care will the nurse prioritize? -
CORRECT ANSWER - Instill 0.5% ophthalmic erythromycin.
A nurse does an initial assessment on a newborn and notes a pulsation over the anterior
fontanelle that corresponds with the newborn's heart rate. How would the nurse interpret this? -
CORRECT ANSWER - It is normal to feel pulsations that correlate with the newborn's
heart rate over the anterior fontanelle.
A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when
he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the
lower central portion of the gums. What would be the nurse's best response? - CORRECT
ANSWER - "Precocious teeth can occur at birth but we may need to remove them to
prevent aspiration."
Parents tell the nurse that they have been told to keep their newborn away from windows and be
sure to cover the baby with a light blanket. They do not understand why this is necessary. What
rationale would the nurse provide for this care? - CORRECT ANSWER - Since newborns
cannot shiver to produce heat, parents need to be sure to keep them covered up and away from
sources of heat loss like a window.