A 9-week-old infant is scheduled for a cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
White blood cell count of 10,000/mm (10x 10/L).
Weight gain of 2 pounds (0.91 kg) since birth.
Red blood cell count of 2.3 cell/mcl or (2.3 x 10/L).
Urine specific gravity is 1.011.
The Correct Answer is C
Answer: C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10/L).
Rationale:
A. White blood cell count of 10,000/mm³ (10 x 10⁹/L): This is within the normal range for an infant, indicating no immediate concern for infection or immune response. It does not need to be urgently conveyed to the surgeon.
B. Weight gain of 2 pounds (0.91 kg) since birth: This is a positive sign indicating healthy growth and nutritional status, but it is not a critical concern that would affect the immediate surgical plan.
C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10⁹/L): This low RBC count indicates anemia, which is critical information for the surgeon. Anemia can increase the risk of complications during and after surgery due to potential issues with oxygenation and healing, making it the most important information to convey.
D. Urine specific gravity is 1.011: This indicates normal hydration status and is not immediately relevant to the surgical procedure. It does not need to be urgently reported to the surgeon compared to the low RBC count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
In a normal infant, T4 levels increase after birth due to stimulation by TSH from the pituitary gland. In this case, the T4 level is low and the TSH level is high, indicating that the thyroid gland is not producing enough T4 in response to TSH stimulation. This suggests that the infant may have congenital hypothyroidism, which requires prompt treatment to prevent developmental delays and other complications.
The low T4 level is not a direct cause of the high TSH level; rather, the high TSH level is a compensatory mechanism to increase T4 production. It is not normal for a breastfeeding infant to have high thyroxine levels. While the thyroid gland may take a few weeks to reach normal function after birth, the persistent low T4 and high TSH levels in this infant suggest a more serious issue.
Correct Answer is C
Explanation
Acute rheumatic fever is a serious inflammatory condition that can develop after a streptococcal infection, particularly if the infection is not treated or resolved properly. The most common initial symptom of acute rheumatic fever is a sore throat, which is usually accompanied by a fever and swollen lymph nodes.
While mumps, chickenpox, and influenza are all infectious diseases, they are not directly linked to the development of acute rheumatic fever. However, a recent or untreated streptococcal infection (such as strep throat) can lead to the development of acute rheumatic fever.
Therefore, when obtaining a health history from a child with a diagnosis of acute rheumatic fever, it is most significant to inquire about recent or untreated sore throat, as this is the most likely cause of the condition.
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