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A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?
- A. Auscultate the lungs for respiratory pneumonia.
- B. Change to latex-free gloves when handling infant.
- C. Draw blood to analyze for streptococcal infection.
- D. Apply zinc oxide to perineum with each diaper change.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations, and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse take next?
- A. Initiate positive pressure ventilation.
- B. Intervene after the one-minute Apgar assessment.
- C. Initiate CPR on the infant.
- D. Assess the infant's blood glucose level.
Correct Answer: A
Rationale: A heart rate below 100 bpm in a newborn indicates bradycardia and requires intervention. Positive pressure ventilation should be initiated to improve oxygenation and help increase the infant's heart rate. This intervention is crucial to support the newborn's transition to extrauterine life and prevent further complications.
The healthcare provider notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the healthcare provider implement first?
- A. Assess cervical dilation.
- B. Change the client's position.
- C. Administer oxygen via facemask.
- D. Turn off the oxytocin infusion.
Correct Answer: B
Rationale: Changing the client's position is the priority intervention for variable decelerations as it can relieve pressure on the umbilical cord, potentially resolving the deceleration and improving fetal oxygenation. Assessing cervical dilation, administering oxygen via facemask, and turning off the oxytocin infusion are important interventions but addressing the fetal distress caused by variable decelerations takes precedence.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate?
- A. Drowsiness and bradycardia.
- B. Depressed reflexes and increased respirations.
- C. Tachycardia and a feeling of nervousness.
- D. A flushed, warm feeling and a dry mouth.
Correct Answer: C
Rationale: The primary side effects of terbutaline sulfate are related to its beta-adrenergic effects. Tachycardia and nervousness are common side effects of terbutaline sulfate. Tachycardia is expected due to the drug's beta-agonist properties, while nervousness can result from the stimulation of beta-adrenergic receptors. It is crucial to monitor the client for these side effects to ensure early recognition and appropriate management.
In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?
- A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
- B. Growth and development have been abnormal since birth.
- C. Muscular strength can be regained with physical exercise and therapy.
- D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client who is 32 weeks' gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Inspect the client's face for edema.
- B. Ascertain the frequency of headaches.
- C. Evaluate for a history of cluster headaches.
- D. Observe and time the client's contractions.
Correct Answer: A
Rationale: Inspecting the client's face for edema is crucial to assess for preeclampsia, a serious condition characterized by high blood pressure during pregnancy. Edema, particularly facial edema, can be a significant indicator of preeclampsia, prompting the need for further evaluation and management to ensure the well-being of both the client and the unborn child.