Answer to Question 1
D
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A Incorrect. In assessing a newborn for jaundice, the nurse will not focus on skin of the scapula, under the arm, and in the groin.
B Incorrect. In assessing a newborn for jaundice, the nurse will not focus on skin under the chin and under the knee.
C Incorrect. In assessing a newborn for jaundice, the nurse will not focus on skin under the scrotum or inside the labia.
D Correct. Observe the color of the skin, especially at the tip of the nose, the external ear, the lips, the hands, and the feet. These areas are prominent locations for detecting cyanosis or jaundice.
Answer to Question 2
C
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A Incorrect. It is not important for the nurse to ask the caregivers about how much their child typically eats at a meal.
B Incorrect. It is not a priority for the nurse to ask the caregivers what foods their child likes. Asking about lactose intolerance is a major priority first. Then it is helpful to know the likes and dislikes of the child.
C Correct. The need for calcium is increased when a child sustains a fracture, and the major source of this mineral is dairy products. Many African-Americans have lactose intolerance in which they are unable to digest lactose found in dairy products. With ingestion of these foods they experience abdominal bloating, diarrhea and excessive flatus. It is important for the nurse to ask the caregivers of this child if the individual is lactose intolerant before telling them about the best foods to serve the child to facilitate healing. If the child is lactose intolerant, he or she may need to obtain calcium from other foods such as green leafy vegetables, soy milk, or take the lactase enzyme replacement before consuming dairy products.
D Incorrect. It is not important for the nurse to ask the caregivers whether they cook at home or eat out most of the time.