A nurse in the emergency department is assessing a 4-month-old infant who has suspected pertussis. Which of the following findings should the nurse identify as consistent with this diagnosis? (Select all that apply.)

Apnea and cyanosis during coughing episodes

Inspiratory stridor with a barking cough

Wheezing with shortness of breath during activity

Paroxysmal coughing followed by a high-pitched "whoop" on inspiration

Dry, hacking cough that worsens at night

Answer and Explanation

Correct Answer : A,D,E

A. Infants, especially those under 6 months, may present with apnea and cyanosis during coughing paroxysms instead of the classic “whoop,” as their respiratory muscles are immature. This is a common severe manifestation in young infants.

B. Inspiratory stridor and a barking cough are characteristic of croup, not pertussis. Croup is usually viral in origin and presents with hoarseness and upper airway obstruction, which differs from pertussis.

C. Wheezing with exertional dyspnea is more typical of asthma or bronchiolitis, not pertussis. While pertussis can cause hypoxia, wheezing is not a defining feature.

D. The paroxysmal stage of pertussis is characterized by repetitive coughing spells followed by a high-pitched inspiratory “whoop”. This is classic for older infants and children, though it may be absent in young infants.

E. In the catarrhal stage, pertussis often begins as a mild, dry cough resembling a common cold, which gradually progresses to severe paroxysms. Nighttime exacerbation is common.

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Correct Answer is A

Explanation

A. Rho(D) immune globulin (RhoGAM) is indicated when an Rh-negative mother gives birth to an Rh-positive infant. This prevents the mother’s immune system from developing antibodies against Rh-positive blood cells, which could cause hemolytic disease of the newborn (HDN) in future pregnancies.

B. An Rh-positive mother already has the D antigen, so she will not form antibodies against an Rh-negative baby. RhoGAM is not needed.

C. The mother is Rh-positive and cannot develop antibodies against Rh-positive fetal blood cells. No RhoGAM is required.

D. Both mother and baby are Rh-negative, so there is no risk of maternal sensitization. RhoGAM is not indicated.

A. Prepare for an emergency cesarean birth. B. Administer Vitamin k. per protocol. C. Increase the magnesium sulfate infusion. D. Assess maternal glucose levels E. Place the client in Trendelenburg position.

Correct Answer is ["A"]

Explanation

A. The client shows signs of magnesium sulfate toxicity: oliguria (urine output <30 mL/hr) and absent deep-tendon reflexes. These are potentially life-threatening signs that require immediate intervention, including preparing for emergent delivery if maternal or fetal status is unstable. Stopping the magnesium infusion and preparing for emergency interventions is critical.

B. Administering Vitamin K is not indicated in this scenario. Vitamin K is used to treat or prevent coagulopathy, such as in newborns or clients on certain anticoagulants, but it does not counteract magnesium toxicity.

C. Increasing the magnesium sulfate infusion would worsen toxicity. The correct action is to stop the infusion immediately and prepare to administer calcium gluconate as an antidote if prescribed.

D. Assessing maternal glucose levels is unrelated to the immediate concern of magnesium toxicity. While glucose monitoring may be part of overall prenatal care, it is not a priority in this emergent situation.

E. Placing the client in Trendelenburg position is not indicated. Positioning does not treat magnesium toxicity and could worsen respiratory compromise in a client with severe preeclampsia. The priority is stopping magnesium, assessing maternal and fetal status, and preparing for emergency delivery if necessary.

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A nurse in the emergency department is assessing a 4-month-old infant who has suspected pertussis. Which of the following findings should the nurse identify as consistent with this diagnosis? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Rho immune globulin will be ordered after birth if which situation occurs?

Correct Answer is A

Explanation

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's urine output for the past hour is 25 mL and deep-tendon reflexes are absent. Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["A"]

Explanation

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