A nurse is caring for a client having a biophysical profile.
The client asks what the test is for.
What should the nurse include in the response? (Select all that apply.)

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

Exercise is encouraged for cystic fibrosis patients as it improves respiratory function and overall physical health. Outdoor activities like swinging and running benefit the child by promoting lung clearance through increased breathing depth, which supports disease management and physical development.

Choice B rationale

Chest therapy and postural drainage improve mucus clearance and lung function in cystic fibrosis patients. Performing these interventions regularly ensures respiratory health by reducing mucus accumulation and preventing infections, promoting the child’s well-being.

Choice C rationale

High-protein, high-calorie diets are essential for cystic fibrosis patients due to increased metabolic demands. Supplementing the diet with high-calorie formula supports weight gain and compensates for malabsorption. These interventions are pivotal for growth and energy maintenance.

Choice D rationale

Pancreatic enzymes are crucial for digestion and nutrient absorption in cystic fibrosis patients, as pancreatic insufficiency leads to malabsorption. Even with good appetite and bowel movements, skipping enzyme supplementation results in nutrient deficiencies, growth delays, and gastrointestinal issues.