A nurse is caring for a 2-year-old male client. The parent states, "He has started playing with dolls since our baby was born. Does this indicate he will identify as a female as he grows up?" Which of the following responses should the nurse make?

"You will also find he will want to wear girts clothes, including dresses, as well”

"Gender identity is generally not established until the child is around five years old”

"At two years of age, toddlers often engage in play that imitates adult actions."

"When a male toddler chooses to play with dolls, it is an indication he will later identify as a female."

Answer and Explanation

The Correct Answer is C

A. "You will also find he will want to wear girls' clothes, including dresses, as well.": This response incorrectly assumes that playing with dolls predicts future behavior regarding gender expression, which is not accurate. It also may cause unnecessary worry for the parent.

B. "Gender identity is generally not established until the child is around five years old.": While partially true, this response does not directly address the parent's concern about the current behavior. It misses the opportunity to explain that imitating caregiving is a normal developmental stage.

C. "At two years of age, toddlers often engage in play that imitates adult actions.": This response correctly explains that toddlers naturally mimic the behavior they observe in adults, including caregiving activities, without it indicating future gender identity. Play is a normal part of development at this age.

D. "When a male toddler chooses to play with dolls, it is an indication he will later identify as a female.": This statement is inaccurate and misleading. A toddler’s choice of toys reflects curiosity and imitation, not a prediction of future gender identity or roles.

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Correct Answer is B

Explanation

A: Image A shows a newborn wrapped in a blanket with generalized redness on the face but without distinct blotchy areas or pustules. This appearance is more consistent with normal transitional skin changes such as acrocyanosis or overall mild skin redness after birth. It does not match the appearance of erythema toxicum.

B: Image B shows a close-up of the newborn’s face with visible small red blotchy spots, especially around the cheeks and nose. This matches the classic presentation of erythema toxicum, a benign newborn rash appearing within the first 24 hours. It is characterized by red patches with possible small pustules scattered over the face and body.

A. Decreased bowel sounds B. Urine output of 360 mL/12 hr C. Blood pressure of 100/74 mm Hg D. Distended neck veins

Correct Answer is D

Explanation

A. Decreased bowel sounds: Decreased bowel sounds are often associated with conditions like ileus, abdominal surgery, or bowel obstruction, rather than directly indicating fluid volume excess. Fluid overload typically affects the cardiovascular and respiratory systems first.

B. Urine output of 360 mL/12 hr: While this is a low urine output and could suggest dehydration or renal impairment, it is more indicative of fluid volume deficit rather than fluid volume excess. Excess fluid volume would generally be associated with adequate or increased urine output if renal function is normal.

C. Blood pressure of 100/74 mm Hg: This blood pressure reading is within normal limits for many adults and does not specifically suggest fluid overload. In cases of fluid volume excess, a client might actually exhibit elevated blood pressure due to increased circulatory volume.

D. Distended neck veins: Distended neck veins, also known as jugular venous distention, are a classic sign of fluid volume excess. They occur because increased intravascular volume causes elevated venous pressure, which becomes visible in the neck veins when the client is positioned at a 30- to 45-degree angle.

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A nurse is caring for a 2-year-old male client. The parent states, "He has started playing with dolls since our baby was born. Does this indicate he will identify as a female as he grows up?" Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who was born 24 hrs ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following findings indicates fluid volume overload?

Correct Answer is D

Explanation

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