A nurse is providing instructions about a 24-hour urine collection to an adolescent client. Which of the following should the nurse include in the teaching?
Discard the first voided specimen.
Void every hour.
Save the final specimen in a separate container.
Cleanse the perineum with a povidone-iodine solution prior to voiding.
The Correct Answer is A
Choice A rationale
The first voided specimen is discarded to ensure that the 24-hour urine collection starts with an empty bladder and accurately reflects the urine produced over the entire period.
Choice B rationale
Voiding every hour is not necessary and may not be practical for a 24-hour urine collection.
Choice C rationale
The final specimen should be included in the same container as the rest of the 24-hour urine collection.
Choice D rationale
Cleansing the perineum with a povidone-iodine solution is not required for a 24-hour urine collection.
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Correct Answer is C
Explanation
Choice A rationale
Checking the newborn’s eyes every 8 hours is not necessary for the management of hyperbilirubinemia or phototherapy. The primary concern during phototherapy is monitoring the newborn’s temperature and hydration status.
Choice B rationale
Placing mittens on the newborn’s hands is unrelated to the management of hyperbilirubinemia or phototherapy. Mittens are typically used to prevent the newborn from scratching themselves.
Choice C rationale
Monitoring the newborn’s temperature every 2 hours is essential during phototherapy because infants are at risk of hypothermia due to increased heat loss from the lights. This helps ensure the newborn maintains a stable body temperature.
Choice D rationale
Applying lotion to the newborn’s skin is not recommended during phototherapy as it can interfere with the effectiveness of the lights. The lotion can act as a barrier, reducing the amount of light that reaches the skin.
Correct Answer is B
Explanation
Choice A rationale
Engaging in parallel play is a normal developmental behavior for an 18-month-old toddler. It indicates that the child is beginning to interact with peers, even if they are not yet playing cooperatively.
Choice B rationale
Walking with assistance at 18 months may indicate a potential developmental delay. By this age, most toddlers should be able to walk independently. If a child is still requiring assistance, it may warrant further evaluation.
Choice C rationale
Speaking at least 10 words is within the expected developmental range for an 18-month-old. This milestone indicates that the child is developing language skills appropriately.
Choice D rationale
Building a tower of 3 blocks is a typical developmental milestone for an 18-month-old. It demonstrates fine motor skills and cognitive development.