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A postterm infant, delivered vaginally, is exhibiting tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these assessment findings are indicative of which condition?
- A. Hypoglycemia
- B. Respiratory distress syndrome
- C. Meconium aspiration syndrome
- D. Transient tachypnea of the newborn
Correct Answer: C
Rationale: Tachypnea, grunting, retractions, and nasal flaring are symptoms of respiratory distress related to meconium aspiration syndrome (MAS). MAS occurs often in postterm infants and develops when meconium in the amniotic fluid enters the lungs during fetal life or at birth. The symptoms noted in the question are unrelated to hypoglycemia. Respiratory distress syndrome is a complication of preterm infants. Transient tachypnea of the newborn is primarily found in infants delivered via cesarean section.
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The nurse plans care for a client requiring intravenous (IV) fluids and electrolytes understanding that which are findings that correlate with the need for this type of therapy? Select all that apply.
- A. Hyponatremia
- B. Bounding pulse rate
- C. Chronic kidney disease
- D. Isolated syncope episodes
- E. Rapid, weak, and thready pulse
- F. Abnormal serum and urine osmolality levels
Correct Answer: A,E,F
Rationale: Abnormal assessment findings of major body systems offer clues to fluid and electrolyte imbalances. Rapid, weak, and thready pulse is an assessment abnormality found with fluid and electrolyte imbalances, such as hyponatremia. Abnormal serum and urine osmolality are laboratory tests that are helpful in identifying the presence of or risk of fluid imbalances. Isolated episodes of syncope are not indicators for intravenous therapy unless fluid and electrolyte imbalances are identified. A bounding pulse rate is a manifestation of fluid volume excess; therefore, IV fluids are not indicated. Clients with chronic kidney disease experience the inability of the kidneys to regulate the body's water balance; fluid restrictions may be used.
The nurse is caring for a client diagnosed with a herniated lumbar intervertebral disk who is experiencing low back pain. Which position should the nurse place the client in to minimize the pain?
- A. Supine with the knees slightly raised
- B. High Fowler's position with the foot of the bed flat
- C. Semi-Fowler's position with the foot of the bed flat
- D. Semi-Fowler's position with the knees slightly raised
Correct Answer: D
Rationale: Clients with low back pain are often more comfortable in the semi-Fowler's position with the knees raised sufficiently to flex the knees (William's position). This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the bed flat or lying in a supine position with the knees raised would excessively stretch the lower back. Keeping the foot of the bed flat will enhance extension of the spine.
The nurse is caring for a child recovering from a tonsillectomy. Which fluid or food item should be offered to the child?
- A. Green Jell-O
- B. Cold soda pop
- C. Butterscotch pudding
- D. Cool cherry-flavored Kool-Aid
Correct Answer: A
Rationale: After tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided because they give the appearance of blood if the child vomits.
When caring for a client diagnosed with myasthenia gravis, the nurse should be alert for which manifestations of myasthenic crisis? Select all that apply.
- A. Bradycardia
- B. Increased diaphoresis
- C. Decreased lacrimation
- D. Bowel and bladder incontinence
- E. Absent cough and swallow reflex
- F. Sudden marked rise in blood pressure
Correct Answer: B,D,E,F
Rationale: Myasthenic crisis is caused by undermedication or can be precipitated by an infection or sudden withdrawal of anticholinesterase medications. It may also occur spontaneously. Clinical manifestations include increased diaphoresis, bowel and bladder incontinence, absent cough and swallow reflex, sudden marked rise in blood pressure because of hypoxia, increased heart rate, severe respiratory distress and cyanosis, increased secretions, increased lacrimation, restlessness, and dysarthria.
A clinical nurse specialist is asked to present a clinical conference to the student group about brain tumors in children younger than 3 years. The nurse should include which information in the presentation?
- A. Radiation is the treatment of choice.
- B. The most significant symptoms are headache and vomiting.
- C. Head shaving is not required before removal of the brain tumor.
- D. Surgery is not normally performed because of the increased risk of functional deficits.
Correct Answer: B
Rationale: The classic symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the tumor. Before surgery, the child's head will be shaved, although every effort is made to shave only as much hair as is necessary. Radiation therapy is avoided in children younger than 3 years because of the toxic side effects on the developing brain, particularly in very young children.