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A nurse is caring for a client who is at 20 weeks of gestation and asks what could cause the infant to have a cleft lip. Which of the following responses should the nurse give?

A cleft lip is caused by the Epstein-Barr virus (EBV)."

"A cleft lip is due to an abnormal autoimmune response."

"A cleft lip is due to advanced maternal age.”

"A cleft lip has a genetic component."

Answer and Explanation

The Correct Answer is D

A. Epstein-Barr virus (EBV) is not associated with cleft lip formation.

B. Cleft lip is not caused by an autoimmune response.

C. Advanced maternal age is associated with other congenital anomalies but not specifically with cleft lip.

D. Cleft lip and palate often have a genetic component and can be influenced by environmental factors during early pregnancy.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Providing frequent updates helps reduce uncertainty and reassures the parents that their child is receiving appropriate care.

B. Encouraging parental participation fosters a sense of control and involvement, which can reduce parental distress.

C. Increased healthcare rounds provide additional opportunities to address any emerging concerns and reassure the parents.

D. Interprofessional rounds at the bedside include the parents in care decisions and offer direct communication with the care team.

E. Educating parents about nursing interventions can reduce their anxiety and help them understand the care their child is receiving.

F. Providing the nurse's personal cell phone number is not appropriate or professional. The hospital should have established communication protocols.

A. An 18-month-old admitted for dehydration 2 days ago who has had six wet diapers in the last 24 hr and ate 90% of their meals B. A 15-year-old adolescent who had a laparoscopic appendectomy 30 hr ago, rates their pain a 3 on a scale of 1 to 10, and is preparing for discharge this morning C. A 3-year-old toddler who aspirated several sunflower seeds and continues to cough with an O. saturation of 91% D. A 6-year-old child admitted with asthma exacerbation who used a rescue inhaler 16 hr ago E. Child's statements with parent input

Correct Answer is C

Explanation

A. The 18-month-old shows signs of improving hydration status, evidenced by adequate wet diapers and food intake. This client is stable.

B. The adolescent with mild postoperative pain and preparing for discharge is stable and does not require immediate attention.

C. The toddler's low oxygen saturation (91%) and continued coughing indicate potential airway obstruction or impaired gas exchange, which requires immediate assessment and intervention to prevent respiratory failure.

D. Although the 6-year-old with asthma should be monitored, their last use of a rescue inhaler 16 hours ago suggests they are not in acute distress.

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A nurse is caring for a client who is at 20 weeks of gestation and asks what could cause the infant to have a cleft lip. Which of the following responses should the nurse give?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse has just received hand-off communication at the start of their shift. After reviewing each client's status, which of the following clients should the nurse see first?

Correct Answer is C

Explanation

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