Choice A rationale

Sunken fontanels are typically a sign of dehydration due to reduced intracranial pressure and are not specific to abusive head trauma. Abusive head trauma often results in elevated intracranial pressure or swelling, which would present differently. Therefore, this finding is unrelated to the mechanisms of abusive head trauma in a 2-month-old.

Choice B rationale

Retinal hemorrhages are strongly associated with abusive head trauma due to the shearing forces during shaking or impact, which rupture retinal blood vessels. This finding is a hallmark of non-accidental trauma in infants, as accidental injuries rarely cause this degree of internal ocular damage.

Choice C rationale

Large bruises on the body could indicate trauma but are not specific to abusive head trauma. Additionally, the pattern or location of bruises is significant for abuse, especially in non-mobile infants. However, bruises alone do not confirm head trauma specifically.

Choice D rationale

Lacerations, such as those on the forearm, might suggest trauma but lack specificity for abusive head trauma. Such injuries are more commonly associated with accidents or other forms of physical abuse that do not necessarily involve the head.

Choice A rationale

Weighing an infant's diaper for output is a task suitable for unlicensed assistive personnel (UAP) because it involves data collection rather than clinical judgment or critical thinking. The results can be recorded and reported to the nurse for further assessment and interpretation.

Choice B rationale

Assessing a post-operative dressing requires clinical judgment to identify signs of infection, dehiscence, or other complications. This task is within the scope of a licensed nurse and should not be delegated to UAP to ensure patient safety.

Choice C rationale

Calculating the Morse Fall Scale involves understanding and interpreting risk factors, which requires critical thinking and clinical judgment. It is inappropriate for delegation to UAP, as they are not trained to analyze or interpret clinical data.

Choice D rationale

Performing an assessment of a child's developmental milestones requires knowledge of growth and development patterns, as well as clinical judgment to interpret findings. This task is outside the scope of UAP and must be performed by a licensed nurse.

Choice A rationale

Liver function tests, while important for identifying hepatic disorders, are not directly associated with polycystic ovarian syndrome (PCOS). PCOS is primarily an endocrine disorder affecting reproductive hormones, not liver function.

Choice B rationale

Blood urea nitrogen (BUN) is used to assess renal function but is not typically relevant for PCOS. PCOS does not inherently affect kidney function, making this test unnecessary in routine monitoring for this condition.

Choice C rationale

Thyroid-stimulating hormone levels are assessed to rule out thyroid dysfunction, which can present with similar symptoms to PCOS. However, thyroid issues are not caused by PCOS and monitoring TSH is not central to PCOS management.

Choice D rationale

Serum glucose levels are critical in PCOS management due to the increased risk of insulin resistance and type 2 diabetes. Monitoring these levels helps to manage glucose metabolism and prevent complications, making it a key parameter in care for PCOS patients.

Choice A rationale

Reporting to a child abuse hotline is a priority intervention when there is a suspicion of non-accidental trauma, such as a spiral fracture in a non-ambulatory infant. Spiral fractures are highly indicative of twisting injuries, which are unlikely to result from a fall and suggest possible abuse.

Choice B rationale

Educating the mother on safety is an important intervention for accidental injuries but does not address the immediate concern of potential abuse. The focus should be on investigating the cause of the injury to ensure the child’s safety.

Choice C rationale

Informing the mother to call the nurse for all diaper changes is not relevant to investigating potential abuse. This action fails to prioritize the safety and protection of the child in cases where abuse is suspected.

Choice D rationale

Completing the Morse Fall Scale assesses fall risk and is not appropriate for investigating the etiology of the injury. It does not address the immediate need to ensure the child’s safety or initiate an investigation into possible abuse.

Choice A rationale

Performing a sharp hand clap near the infant activates the Moro reflex, a startle response present at birth that integrates by around six months of age. The reflex involves symmetric extension and abduction of the arms followed by flexion, demonstrating proper neurological function.

Choice B rationale

Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. This reflex involves flexion of the toes when pressure is applied to the sole and is unrelated to startling the infant.

Choice C rationale

Holding the newborn vertically allowing one foot to touch the table surface elicits the stepping reflex, not the Moro reflex. This reflex involves simulated walking movements and is unrelated to assessing startle responses.

Choice D rationale

Turning the newborn's head quickly to one side elicits the tonic neck reflex (fencing reflex) rather than the Moro reflex. This reflex involves extension of the limbs on the side the head is turned and flexion on the opposite side. .

Choice A rationale

Maximizing skin exposure to phototherapy lights ensures effective breakdown of bilirubin through photoisomerization, reducing serum bilirubin levels. Phototherapy converts unconjugated bilirubin to water-soluble isomers that are excreted via bile and urine. Exposing more skin enhances light absorption, increasing treatment efficacy. Normal bilirubin levels in newborns range from 1 to 12 mg/dL. This intervention aligns with standard protocols for managing hyperbilirubinemia in neonates.

Choice B rationale

Applying lotion during phototherapy can cause skin burns by altering light penetration and causing a thermal effect. It may also increase the risk of skin irritation and infections. Phototherapy lights generate heat, and lotions can exacerbate these effects, leading to complications. Effective bilirubin management depends on clean, dry skin under the lights.

Choice C rationale

While eye shields are critical to protecting the infant’s retina and cornea from potential phototoxicity, removing them during breastfeeding is necessary. This promotes bonding and facilitates feeding. Continuous shield use can obstruct parental interaction and feeding, which are vital for infant care. Shielding should only occur during phototherapy exposure.

Choice D rationale

Swaddling restricts skin exposure to the therapeutic lights, negating the benefits of phototherapy. It prevents effective breakdown of bilirubin as less skin is exposed to the treatment. Neonates under phototherapy should be minimally clothed, often only wearing a diaper, to maximize light absorption and ensure treatment success.

Choice A rationale

Infrequent or inconsistent feedings lead to milk stasis, providing an environment conducive to bacterial growth, which can result in mastitis. Proper breastfeeding frequency ensures milk drainage, reducing stasis and infection risk. Milk stasis is a primary contributor to the development of mastitis, emphasizing the importance of regular feeding practices.

Choice B rationale

Nipple cracks and fissures are a direct portal for bacterial entry, increasing the likelihood of infection in the lactiferous ducts. Staphylococcus aureus, commonly present on the skin, can invade through damaged tissue, resulting in mastitis. Proper nipple care and hygiene are essential in prevention.

Choice C rationale

Gradual weaning allows for a decrease in milk production, preventing engorgement and stasis, which reduces the risk of mastitis. Gradual weaning gives the mammary glands time to adapt. Mastitis is more commonly associated with abrupt changes in feeding patterns or milk stasis rather than controlled weaning processes.

Choice D rationale

Engorgement from oversupply creates increased intraductal pressure, which can lead to blocked ducts and milk stasis, creating conditions favorable for bacterial growth. Engorgement needs prompt management to prevent secondary infections such as mastitis, particularly in lactating individuals.

Choice A rationale

A history of breast cancer is a contraindication for menopausal hormone therapy (HT) due to its potential to stimulate hormone receptor-positive cancer cells. Estrogen, a component of HT, may promote the growth of residual malignant cells. HT must be avoided to minimize the recurrence risk. Regular screening and alternative symptom management are recommended for these patients.

Choice B rationale

GERD management with proton pump inhibitors or H2 receptor antagonists does not contraindicate HT. These conditions are unrelated to hormone therapy risks or benefits. HT may even aid in esophageal mucosal protection in some menopausal women, but only under clinical evaluation.

Choice C rationale

Dermatitis, being a localized skin condition, has no direct correlation to HT contraindications. While some patients may report worsened symptoms with HT, it is not a standard exclusion criterion. Hormone therapy decisions should focus on systemic and oncological considerations rather than minor dermatologic history.

Choice D rationale

COPD, while a chronic respiratory condition, is not a standard contraindication for HT. Careful evaluation of cardiopulmonary status is necessary before initiating HT, as estrogen may influence thromboembolic risk, particularly in sedentary individuals, but it is not specifically contraindicated in COPD cases.

Choice A rationale

Plantar creases appear over the entire sole closer to term gestation (37-40 weeks). At 30 weeks, these creases are confined to the anterior sole, reflecting the immature integumentary system. Absence of full creases correlates with preterm gestational age, assisting in clinical age assessment of neonates.

Choice B rationale

Preterm neonates at 30 weeks exhibit hypotonia, with minimal extremity flexion. Flexion develops progressively as the central nervous system matures. Hypotonia reflects developmental immaturity and is a distinguishing feature in preterm infants compared to term neonates.

Choice C rationale

Subcutaneous fat deposition is limited in preterm neonates, contributing to their thin, translucent skin and increased risk of thermoregulation issues. Fat accumulation occurs primarily in the third trimester, and its absence is a hallmark of premature neonates, requiring external temperature support.

Choice D rationale

Lanugo, a fine hair covering the body, is prominent in neonates born at 30 weeks. It serves as an adaptive mechanism for thermoregulation in utero. Lanugo decreases closer to term as subcutaneous fat increases. Its presence confirms preterm status and aids in gestational age assessment.

Choice A rationale

Restricting play activity limits physical and emotional well-being in children. While strenuous activity is discouraged during recovery, moderate activity promotes overall health and blood flow. Over-restriction is unwarranted without clinical indications. Balance in physical activity should be emphasized in sickle cell management.

Choice B rationale

Cold compresses induce vasoconstriction, which may precipitate a sickle cell crisis by reducing oxygen delivery to tissues. Warm compresses are preferred to improve blood flow and alleviate pain in these patients. Temperature management is critical in preventing vaso-occlusive complications.

Choice C rationale

Adequate hydration reduces blood viscosity, preventing sickling episodes in children with sickle cell anemia. Consistent fluid intake is a cornerstone of management, mitigating crisis frequency. Parents should encourage routine hydration to maintain hemodynamic stability in affected children.

Choice D rationale

Daily temperature monitoring is important but not sufficient standalone advice. Fever in sickle cell anemia may indicate infection or crisis, requiring prompt medical evaluation. However, comprehensive management includes hydration, pain control, and activity regulation alongside temperature monitoring. .