The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.
The parent reports no signs of watery stools.
What nursing intervention should the nurse implement?

Advise the parent to reduce the infant’s fruit intake for 24 hours.

Recommend the parent to clean with soap and water at each diaper change.

Instruct the parent to change the child’s diaper more frequently.

Encourage the parent to apply lotion with each diaper change.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Reducing the infant’s fruit intake for 24 hours is not the best approach in this situation. While certain fruits can cause diarrhea, the parent reports no signs of watery stools. Therefore, this intervention may not address the issue of the red and raw diaper area.

Choice B rationale

Cleaning with soap and water at each diaper change can actually worsen the condition. Soap can dry out the skin and disrupt the skin’s natural barrier, potentially leading to more irritation. It’s generally recommended to use water and a soft cloth, or a gentle non-soap cleanser, to clean the diaper area.

Choice C rationale

Changing the child’s diaper more frequently is the most appropriate intervention. A wet or dirty diaper can irritate the skin, leading to diaper rash. By changing the diaper more often, the skin is kept clean and dry, which can help the rash heal.

Choice D rationale

Applying lotion with each diaper change is not typically recommended for diaper rash. Some lotions can contain fragrances or other ingredients that can further irritate the rash. Instead, a barrier cream or ointment, such as one containing zinc oxide, is often recommended.

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Correct Answer is C

Explanation

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

A. Diaphragmatic respirations. B. Resting respiratory rate of 35 breaths/min. C. Bilateral bronchial breath sounds. D. Flaring of the nares.

Correct Answer is D

Explanation

Choice A rationale

Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.

Choice B rationale

A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.

Choice C rationale

Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.

Choice D rationale

Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.

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The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.The parent reports no signs of watery stools.What nursing intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is C

Explanation

A parent brings a 4-month-old infant to the clinic.The infant has had a runny nose, a slight fever, and a cough for the last two days.Which of the following findings should alert the nurse that the child is in acute respiratory distress?

Correct Answer is D

Explanation

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The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.
The parent reports no signs of watery stools.
What nursing intervention should the nurse implement?