A visiting nurse is making a home visit on a male 2-month-old ...

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A visiting nurse is making a home visit on a male 2-month-old child who was born prematurely. The nurse notes that the child has not been circumcised. What action by the nurse is most important?
 
  A.
  Assess the number of the baby's wet diapers per day.
  B.
  Give parents a referral to have the child circumcised.
  C.
  Instruct parents not to retract the foreskin until after age 1.
  D.
  Teach parents to retract the foreskin for cleaning.

Question 2

A toddler is brought to the clinic with a low-grade fever and the mother describes a grunting sound made by the child on expiration. The respiratory rate is 24 breaths/minute. What action by the nurse is most appropriate?
 
  A.
  Assess nose and throat for foreign bodies.
  B.
  Facilitate a stat chest x-ray.
  C.
  Obtain an oxygen saturation; notify provider.
  D.
  Weigh and measure child then calculate BMI.

[quynhmickitran]

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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TYSM

[lindahyatt42]

Excellent