The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.
The parent reports no signs of watery stools.
What nursing intervention should the nurse implement?

Advise the parent to reduce the infant’s fruit intake for 24 hours.

Recommend the parent to clean with soap and water at each diaper change.

Instruct the parent to change the child’s diaper more frequently.

Encourage the parent to apply lotion with each diaper change.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Reducing the infant’s fruit intake for 24 hours is not the best approach in this situation. While certain fruits can cause diarrhea, the parent reports no signs of watery stools. Therefore, this intervention may not address the issue of the red and raw diaper area.

Choice B rationale

Cleaning with soap and water at each diaper change can actually worsen the condition. Soap can dry out the skin and disrupt the skin’s natural barrier, potentially leading to more irritation. It’s generally recommended to use water and a soft cloth, or a gentle non-soap cleanser, to clean the diaper area.

Choice C rationale

Changing the child’s diaper more frequently is the most appropriate intervention. A wet or dirty diaper can irritate the skin, leading to diaper rash. By changing the diaper more often, the skin is kept clean and dry, which can help the rash heal.

Choice D rationale

Applying lotion with each diaper change is not typically recommended for diaper rash. Some lotions can contain fragrances or other ingredients that can further irritate the rash. Instead, a barrier cream or ointment, such as one containing zinc oxide, is often recommended.

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Correct Answer is C

Explanation

Choice A rationale

A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.

Choice B rationale

Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.

Choice C rationale

A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.

Choice D rationale

A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.

A. Fresh fruits and vegetables. B. Low fat dairy products. C. Water and herbal teas. D. Iron-rich meats.

Correct Answer is B

Explanation

Choice A rationale

While fresh fruits and vegetables are part of a healthy diet, they are not specifically recommended for the prevention of osteoporosis. They do not contain significant amounts of calcium, which is crucial for bone health.

Choice B rationale

Low fat dairy products are a good source of calcium, which is essential for bone health and the prevention of osteoporosis.

Choice C rationale

While water and herbal teas can contribute to overall hydration, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

Choice D rationale

While iron-rich meats contribute to overall health, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

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The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.The parent reports no signs of watery stools.What nursing intervention should the nurse implement?

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The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.
The parent reports no signs of watery stools.
What nursing intervention should the nurse implement?