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A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
- A. Muscle tension decreases with fine motor skill projects, so these activities should be encouraged.
- B. The chorea or movements are temporary and will eventually disappear.
- C. Permanent lifestyle changes are needed to promote safety in the home.
- D. Consistent discipline is not directly related to controlling the movements.
Correct Answer: B
Rationale: Chorea, or sudden aimless movements associated with rheumatic fever, is temporary in nature and will eventually disappear on its own. It is important for the nurse to reassure the parents that these movements are part of the condition and typically resolve over time without the need for permanent lifestyle changes or strict discipline. Providing accurate information and reassurance to the parents can help alleviate concerns and promote understanding of the condition's course.
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The healthcare provider is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg. Which action is the highest priority?
- A. Provide a quiet environment with subdued lighting.
- B. Have calcium gluconate immediately available.
- C. Assess deep tendon reflexes (DTRs) every 4 hours.
- D. Insert a Foley catheter with a urimeter to monitor hourly output.
Correct Answer: B
Rationale: Having calcium gluconate readily available is crucial when administering magnesium sulfate, as it serves as the antidote in case of magnesium toxicity. Magnesium sulfate can lead to respiratory depression and cardiac arrest in cases of overdose or toxicity, making the prompt availability of calcium gluconate essential for immediate administration to counteract these effects.
What is the most important assessment for the healthcare provider to conduct before the administration of epidural anesthesia to a client at 40 weeks' gestation?
- A. Maternal blood pressure.
- B. Level of pain sensation.
- C. Station of presenting part.
- D. Variability of fetal heart rate.
Correct Answer: A
Rationale: Assessing maternal blood pressure is crucial before administering epidural anesthesia because it can cause hypotension, affecting both the mother and the fetus. Hypotension can lead to decreased placental perfusion, potentially compromising the fetal oxygen supply. Monitoring and maintaining maternal blood pressure within a safe range are essential to ensure the well-being of both the mother and the fetus during the administration of epidural anesthesia.
When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?
- A. Measure bilirubin levels using transcutaneous bilirubinometry.
- B. Evaluate cord blood Coombs test results.
- C. Review maternal medical records for blood type and Rh factor.
- D. Prepare the newborn for phototherapy.
Correct Answer: A
Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.
The healthcare provider is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning the infant's care?
- A. Blood pressure 76/42 mmHg.
- B. Faint heart murmur.
- C. Respiratory rate of 76 breaths/minute.
- D. Blood glucose 45 mg/dl.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above the level of her heart. Which assessment finding should the healthcare provider be reported to immediately?
- A. Itching sensation under the cast.
- B. Swelling of fingers with brisk capillary refill.
- C. Numbness and inability to move fingers.
- D. Visible bruising above the cast.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.