Answer to Question 1
ANS: C
The foreskin of an uncircumcised male baby should not be forcibly retracted until after he is 1 year of age. Assessing the number of wet diapers per day is important for any infant and is not directly related to the uncircumcised baby. The nurse should not just give a referral for circumcision, as the parents have chosen the option of not circumcising their baby, which may be for personal, religious, or cultural reasons. After 1 year of age, the foreskin will need to be retracted for cleaning. It should be returned to its original position afterward.
Answer to Question 2
ANS: C
Grunting noises are heard at the end of expiration and are caused by glottal closing. They can be indicative of respiratory distress or pneumonia. This child's respiratory rate is normal for age. The nurse should perform further assessments and notify the provider. Grunting is not associated with foreign bodies. The child is stable and does not need a stat chest x-ray, although he or she probably will have one after being seen. The BMI might be important for a child who snores or breathes noisily because snoring is often associated with obesity (along with foreign body, nasal polyps, choanal obstruction, or hypertrophied adenoid tissue).
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The patient and his family meet with the nurse to discuss progress on the patient care plan.
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