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For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)?
- A. Hemoglobin 10.2 mg/dL and uterine tenderness
- B. Polyuria and weight loss of 3 pounds in the last month
- C. Blood pressure 168/110 and 3+ proteinuria
- D. Hematuria and blood glucose of 160 mg/dL
Correct Answer: C
Rationale: The correct answer is C: Blood pressure 168/110 and 3+ proteinuria. Pregnancy-induced hypertension (PIH) is characterized by high blood pressure (systolic ≥140 mmHg and/or diastolic ≥90 mmHg) and proteinuria. In this case, the blood pressure reading of 168/110 indicates hypertension, and 3+ proteinuria indicates significant protein in the urine, both of which are key diagnostic criteria for PIH.
A: Hemoglobin 10.2 mg/dL and uterine tenderness - These are not specific indicators of PIH.
B: Polyuria and weight loss of 3 pounds in the last month - These symptoms are not typically associated with PIH.
D: Hematuria and blood glucose of 160 mg/dL - Hematuria suggests blood in the urine, which is not a typical finding in PIH, and elevated blood glucose is more indicative of diabetes rather than PIH.
Therefore,
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A nurse is reinforcing home care instructions with the parents of a 5-year-old child who has acute bronchitis. In order to prevent the transmission of the virus, which of the following should the nurse include in the instructions?
- A. Isolate the child in a bedroom separated from the rest of the family.
- B. Teach the child to wash his hands after coughing secretions into a tissue.
- C. Serve food to the child on disposable dishes with plastic utensils.
- D. Have the child wear a mask whenever leaving the bedroom.
Correct Answer: B
Rationale: The correct answer is B: Teach the child to wash his hands after coughing secretions into a tissue. This is because handwashing is one of the most effective ways to prevent the transmission of viruses, including acute bronchitis. By washing hands after coughing into a tissue, the child can reduce the spread of germs to others.
Choice A is incorrect because isolating the child in a bedroom may not be practical or necessary for preventing transmission. Choice C is incorrect as there is no evidence to support that serving food on disposable dishes with plastic utensils prevents transmission of the virus. Choice D is incorrect as wearing a mask whenever leaving the bedroom may not be necessary if proper hand hygiene is practiced.
The parents of a 5-month-old infant state that their infant seems to eat very little. Most of the food comes out of the infant's mouth and onto his clothes.
- A. "Give the baby a bottle of formula before solid food to assure adequate caloric intake."'
- B. "Stop the solid foods and try again when the baby is 12 months old."'
- C. "Put the cereal in a bottle and feed the baby through a nipple with a large hole."'
- D. "Place the food in the back of the baby's mouth using a long-handled spoon."'
Correct Answer: D
Rationale: The correct answer is D because at 5 months, infants are typically ready to start experimenting with solid foods. Placing the food in the back of the baby's mouth using a long-handled spoon helps prevent the baby from pushing the food out with their tongue reflex, allowing for more successful feeding. This method also encourages the baby to learn how to swallow solids properly. Choice A is incorrect as giving formula before solid food won't address the feeding issue. Choice B is incorrect as stopping solid foods until 12 months can hinder the baby's developmental milestones. Choice C is incorrect as feeding cereal in a bottle can increase the risk of choking and doesn't address the underlying issue of feeding difficulty.
A nurse is preparing a room for the admission of a client with sickle cell anemia who is in vasoocclusive crisis. Which type of equipment should the nurse place in the client's room?
- A. Wheelchair with adjustable leg rests
- B. A radio and age-appropriate reading materials
- C. Extra blankets and pillows
- D. Blood transfusion equipment
Correct Answer: D
Rationale: The correct answer is D: Blood transfusion equipment. In a vasoocclusive crisis, the client with sickle cell anemia may require blood transfusions to improve oxygen delivery to tissues. Having blood transfusion equipment readily available in the client's room ensures prompt initiation of treatment. Wheelchair (A) and comfort items like extra blankets and pillows (C) are important but not essential during a vasoocclusive crisis. A radio and reading materials (B) are not directly related to the client's immediate medical needs.
Which explanation is most appropriate when describing physiological jaundice to the parents of a newborn?
- A. The baby has a minor incompatibility of the blood.
- B. The baby is breaking down the extra red blood cells that were present at birth.
- C. The baby is getting too much breast milk, but this is not dangerous.
- D. The baby may have gotten exposed to hepatitis B during the delivery.
Correct Answer: B
Rationale: The correct answer is B: The baby is breaking down the extra red blood cells that were present at birth. Physiological jaundice in newborns occurs due to the breakdown of excess red blood cells, leading to an increase in bilirubin levels. This is a normal process as the baby's liver is still maturing.
Choice A is incorrect because minor blood incompatibility usually leads to a condition known as hemolytic disease of the newborn, not physiological jaundice. Choice C is incorrect as breast milk does not cause physiological jaundice. Choice D is incorrect because hepatitis B exposure does not directly cause physiological jaundice in newborns.
An hour after delivery, a 4000 gram infant exhibits pallor, jitteriness, a blood sugar level of 40 gm/dL, irritability and periodic apnea. Which maternal condition could be the cause of the newborn's symptoms?
- A. Drug addiction
- B. Pregnancy-induced hypertension
- C. TORCH infection
- D. Gestational diabetes
Correct Answer: D
Rationale: The correct answer is D: Gestational diabetes. Infants born to mothers with gestational diabetes are at risk for hypoglycemia due to excessive production of insulin in response to maternal hyperglycemia. This causes the infant's blood sugar level to drop, leading to symptoms such as pallor, jitteriness, irritability, and apnea. The maternal condition directly affects the newborn's blood sugar levels, explaining the infant's symptoms.
Choice A: Drug addiction does not directly cause hypoglycemia in the newborn.
Choice B: Pregnancy-induced hypertension would not typically result in hypoglycemia in the newborn.
Choice C: TORCH infections are unlikely to cause the specific symptoms described in the newborn.
In summary, only gestational diabetes directly affects the newborn's blood sugar levels, leading to the observed symptoms.