The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appear slightly yellow. Additionally, urine in his diaper appears tea-colored.

This child should receive follow- up assessment for what condition?

Intussusception.

Biliary atresia.

Hirschsprung's disease.

Huntington's disease.

Answer and Explanation

The Correct Answer is B

Biliary atresia is a condition that can cause jaundice in newborns and infants, and it can also lead to tea-colored urine due to the presence of bilirubin in the urine. Infants with biliary atresia require further assessment and treatment, including possible surgery, to prevent liver damage and other complications.

A. Intussusception is a condition in which a part of the intestine folds into itself, causing an obstruction, but it does not typically present with jaundice or tea-colored urine.

C. Hirschsprung's disease is a congenital condition that aﬀects the large intestine and can cause bowel obstruction, but it also does not typically present with jaundice or tea-colored urine.

D. Huntington's disease is a genetic neurological disorder that typically does not present in infants and does not cause jaundice or tea-colored urine.

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Correct Answer is A

Explanation

For an eight-month-old infant with heart failure, the nurse should withhold digoxin if the infant's apical pulse is less than 90 beats/minute and notify the healthcare provider. In this case, the infant's apical pulse is 88 beats/minute, so the nurse should withhold the digoxin and notify the healthcare provider.

Furosemide ( B), hydralazine (C), and enalapril (D) do not have specific parameters for withholding based on the infant's vital signs.

A. Have the child blow a cotton ball and have the parent catch it. B. Place a toy in the child's hands while listening to the breath sounds. C. Oﬀer the child bubbles before the stethoscope is placed. D. Allow the child to use a stethoscope on a stuﬀed animal.

Correct Answer is D

Explanation

To ensure the cooperation of a preschooler during an assessment of lung sounds, the nurse can allow the child to use a stethoscope on a stuﬀed animal. This helps the child understand what is happening and feel more comfortable with the procedure. Having the child blow a cotton ball (A), placing a toy in the child's hands (B), and oﬀering bubbles (C ) may distract the child but do not directly involve them in the procedure.

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The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appear slightly yellow. Additionally, urine in his diaper appears tea-colored. This child should receive follow- up assessment for what condition?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

Correct Answer is D

Explanation

The parents of a child with Wilms tumor ask the nurse why surgery is necessary before a biopsy is performed. Which information should the nurse provide?

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The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appear slightly yellow. Additionally, urine in his diaper appears tea-colored.

This child should receive follow- up assessment for what condition?