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A parent of a child with glomerulonephritis asks why the urine is discolored. Which is the best response?
- A. It is not uncommon when children take steroids and BP medications.
- B. There is blood in your child's urine, which causes it to be tea-colored.
- C. The urine is concentrated.
- D. A ketogenic diet can cause tea-colored urine.
Correct Answer: B
Rationale: Hematuria (blood in the urine) is a common finding in glomerulonephritis and causes a tea-colored appearance.
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The nurse observes that a new mother avoids making eye contact with her newborn. The nurse should perform which action?
- A. Examine newborn's eyes for ability to focus.
- B. Assess for other attachment behaviors.
- C. Recognize this as a common reaction in new mothers.
- D. Ask mother why she won't look at newborn.
Correct Answer: B
Rationale: The nurse should assess for other attachment behaviors when a new mother avoids making eye contact with her newborn. This behavior may indicate difficulty forming an emotional bond with the newborn, which can impact the mother-infant relationship. By assessing for other attachment behaviors, the nurse can gather more information to understand the mother's response and provide appropriate support and interventions. Simply recognizing this as a common reaction or asking the mother why she won't look at the newborn may not address the underlying attachment issues that may be present. Examining the newborn's eyes for ability to focus is not relevant in this situation and does not address the mother's behavior.
A 4-month old infant who has a congenital heart defect develops heart failure and is exhibiting marked dyspnea at rest . The nurse is aware this finding can be attributed to:
- A. Anemia
- B. Hypovolemia
- C. Pulmonary edema
- D. Metabolic acidosis blood specimen is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first?
Correct Answer: C
Rationale: The nurse would first assess for an irregular heart rate and rhythm. In a 4-month old infant with a congenital heart defect experiencing marked dyspnea at rest, the sudden onset of cyanosis (blue coloration) and increased respiratory rate can indicate worsening heart failure and potential arrhythmias. Assessing for any abnormal heart rhythms is a priority to determine if immediate intervention is required to stabilize the infant's condition and prevent further deterioration.
The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:
- A. Patient's face is relaxed during conversation.
- B. Patient speaks in a very loud voice.
- C. Patient turns toward person speaking.
- D. Patient is withdrawn.
Correct Answer: A
Rationale: A relaxed face during conversation is not typically indicative of hearing loss. In fact, individuals with hearing loss may exhibit signs such as speaking loudly (Choice B), turning toward the person speaking (Choice C), and feeling withdrawn (Choice D) due to difficulty in hearing and understanding conversations. The act of speaking loudly may be an attempt to compensate for the perceived hearing loss, while turning toward the speaker is a common strategy to better hear and lip-read. Withdrawal can result from the frustration and isolation caused by the inability to fully engage in conversations. Ultimately, a relaxed face during conversation is less likely to be a red flag for hearing loss compared to the other choices provided.
Aisa is to have blood transfusion. Which of the following problems is most likely associated with blood transfusion?
- A. Serum hepatitis
- B. Pulmonary edema
- C. Allergic response
- D. Hemolytic reaction Situation: Joel is a toddler who has classical hemophilia.
Correct Answer: D
Rationale: A hemolytic reaction is the most likely problem associated with blood transfusion. A hemolytic reaction occurs when the body's immune system attacks the transfused blood, leading to the destruction of red blood cells. This reaction can cause serious complications, including kidney damage, shock, and even death. It is crucial for healthcare providers to carefully match blood types and perform compatibility testing before administering a blood transfusion to minimize the risk of a hemolytic reaction. Serum hepatitis, pulmonary edema, and allergic responses are potential complications of blood transfusions, but hemolytic reactions pose the most immediate and severe threat to the patient's health.
Which of the following malignancies is least likely to occur in a 10-month-old infant?
- A. neuroblastoma
- B. nephroblastoma
- C. retinoblastoma
- D. hepatoblastoma
Correct Answer: D
Rationale: Hepatoblastoma is rare in infants under 1 year old, being more common in toddlers.