What measure of fluid balance status is most useful in a child with acute glomerulonephritis?
- A. Proteinuria
- B. Daily weight
- C. Specific gravity
- D. Intake and output
Correct Answer: B
Rationale: Daily weight is the most accurate measure of fluid balance in children with acute glomerulonephritis, as it reflects changes in body fluid status more reliably than other measures like proteinuria or specific gravity.
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When taking a child's blood pressure, what percentage of the upper arm should the nurse ensure the cuff bladder width covers?
- A. 20%
- B. 40%
- C. 60%
- D. 80%
Correct Answer: B
Rationale: When taking a child's blood pressure, the nurse should select a cuff with a bladder width that covers 40% of the arm circumference at the midpoint of the upper arm. This ensures accurate readings. Choosing a cuff that covers less or more than 40% can lead to incorrect blood pressure measurements. Therefore, options A, C, and D are incorrect.
Parents of a newborn with ambiguous genitalia want to know how long they will have to wait to know whether they have a boy or a girl. The nurse answers the parents based on what knowledge?
- A. Chromosome analysis will be complete in 7 days.
- B. A physical examination will be able to provide a definitive answer.
- C. Additional laboratory testing is necessary to assign the correct gender.
- D. Gender assignment involves collaboration between the parents and a multidisciplinary team.
Correct Answer: D
Rationale: Gender assignment in cases of ambiguous genitalia is a complex process that requires a multidisciplinary approach, including genetic, endocrinological, and psychological evaluations. The decision should be made collaboratively with the parents.
The parent of a 1-month-old infant voices concern about the infant's respirations. The parent states the respirations are rapid and irregular. Which information should the nurse provide?
- A. The normal respiratory rate for an infant at this age is between 20 and 30 breaths per minute.
- B. The respirations of a 1-month-old infant are normally irregular and periodically pause.
- C. An infant at this age should have regular respirations.
- D. The irregularity of the infant's respirations is concerning; I will notify the health care provider.
Correct Answer: B
Rationale: The correct answer is B. Irregular respirations with periodic pauses are normal in a 1-month-old infant. Choice A is incorrect because the normal respiratory rate for an infant at this age is higher than the range provided. Choice C is incorrect as irregular respirations are expected in infants. Choice D is not appropriate as irregular respirations with periodic pauses are a normal finding in young infants and do not necessarily indicate a concern that requires immediate notification of the healthcare provider.
Why are neonates predisposed to problems with thermoregulation?
- A. Renal function is not fully developed.
- B. Flexed posture favors heat loss.
- C. A large body surface area favors heat loss to the environment.
- D. A thick layer of subcutaneous fat provides excellent insulation.
Correct Answer: C
Rationale: Neonates have a large surface area relative to their weight, which makes them prone to heat loss to the environment, leading to thermoregulation issues. The underdeveloped kidney affecting urine concentration (Choice A) is unrelated to the thermal regulation process. While a flexed posture can help retain heat (Choice B), it does not outweigh the impact of the large body surface area in neonates. Although subcutaneous fat (Choice D) provides insulation, in neonates, the large body surface area is more significant in contributing to heat loss than the fat's insulating properties.
The nurse is caring for a child with a urinary tract infection who is on intravenous gentamicin (Garamycin). What interventions should the nurse plan for this child with regard to this medication? (Select all that apply.)
- A. Encourage fluids.
- B. Monitor urinary output.
- C. Monitor sodium serum levels.
- D. All above
Correct Answer: D
Rationale: Gentamicin is an aminoglycoside antibiotic that requires monitoring of serum peak and trough levels to avoid toxicity, particularly nephrotoxicity and ototoxicity. Encouraging fluids and monitoring urinary output are also crucial to minimize the risk of kidney damage.