A 2-month-old infant contracts a disease through vertical transmission.
Which situation should the nurse investigate further to ascertain how the infant might have been exposed to the disease?

Answer and explanation

The correct answers are Choices B, C, D, and E.

Choice A rationale

Encouraging the client to “keep doing whatever you are doing” is not an appropriate intervention for a client with a blood pressure reading of 138/80 mm Hg. This blood pressure reading is considered elevated and could indicate pre-hypertension. Therefore, the nurse should assess the client’s lifestyle and other risk factors for hypertension, ask the client about any current antihypertensive medications, obtain another blood pressure reading to verify the first reading, and recommend further evaluation for possible pre-hypertension.

Choice B rationale

Assessing the client’s lifestyle and other risk factors for hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Lifestyle factors, such as diet, physical activity, alcohol consumption, and tobacco use, can significantly influence

blood pressure levels. Therefore, the nurse should assess these factors and provide appropriate education and interventions.

Choice C rationale

Asking the client about any current antihypertensive medications is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. The client may be taking medications that could affect their blood pressure. Therefore, the nurse should ask about these medications and consider their potential impact on the client’s blood pressure.

Choice D rationale

Obtaining another blood pressure reading to verify the first reading is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Blood pressure can fluctuate throughout the day and can be influenced by various factors, such as stress, physical activity, and caffeine consumption. Therefore, the nurse should obtain another reading to confirm the initial measurement.

Choice E rationale

Recommending further evaluation for possible pre-hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. A blood pressure reading of 138/80 mm Hg is considered elevated and could indicate pre-hypertension. Therefore, the nurse should recommend further evaluation to confirm this diagnosis and determine appropriate treatment.

Answer and explanation The correct answer is D. Choice A rationale

While the discussion of food exchanges and calories being well-attended indicates interest and engagement in the class, it does not necessarily reflect an improvement in the clients’ management of their diabetes.

Choice B rationale

Parking convenience for attendees, while important for accessibility and attendance, does not provide information about the effectiveness of the classes in improving diabetes management.

Choice C rationale

Demonstrating the use of a blood glucose meter can be an effective teaching strategy, but it does not provide measurable outcomes related to the clients’ diabetes control.

Choice D rationale

Fasting blood glucose average readings being 20% lower at the end of the classes is a direct and measurable outcome that indicates improved diabetes control. This suggests that the classes were effective in teaching clients how to better manage their type 2 diabetes.