A nurse is discharging a child who has recovered from an acute crisis episode of sickle cell anemia. What instructions should the nurse include in the teaching?

“Offer fluids to your child multiple times every day.”.

“Monitor your child’s temperature daily.”.

“Apply cold compresses when your child expresses pain.”.

“Restrict outdoor play activity to 1 hour per day.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Hydration is crucial for children who have recovered from an acute crisis episode of sickle cell anemia. Dehydration can increase the risk of a sickle cell crisis by making the blood more concentrated. Offering fluids to the child multiple times every day can help prevent dehydration.
Choice B rationale
Monitoring the child’s temperature daily can help detect any infections early. Infections can trigger a sickle cell crisis. However, this is not the most critical instruction for the nurse to include in the teaching.
Choice C rationale
Applying cold compresses when the child expresses pain is not recommended. Cold can cause vasoconstriction, which can lead to a decrease in blood flow and potentially trigger a sickle cell crisis.
Choice D rationale
Restricting outdoor play activity to 1 hour per day is not necessarily required for children who have recovered from an acute crisis episode of sickle cell anemia. Physical activity is generally beneficial for children’s health and well-being.

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Correct Answer is D

Explanation

Choice D rationale
The client is experiencing the first stage, latent phase of labor. This phase is characterized by contractions that are typically mild and irregular, occurring every 5-30 minutes and lasting about 30-45 seconds. The cervix dilates from 0 to 3 cm and effaces from 0% to 40%. The fetus descends into the pelvis, but is not yet engaged. The client may feel excited and anxious as labor begins.
Choice A rationale
The first stage, active phase of labor is characterized by regular, strong contractions occurring every 3-5 minutes and lasting about 40-70 seconds. The cervix dilates from 4 to 7 cm and effaces from 40% to 100%. The fetus descends and engages in the pelvis. The client may feel increased discomfort and a strong urge to bear down.
Choice B rationale
The first stage, transition phase of labor is characterized by intense contractions occurring every 2-3 minutes and lasting about 45-90 seconds. The cervix dilates from 8 to 10 cm and effaces from 100%. The fetus descends and engages in the pelvis. The client may feel overwhelmed, restless, and irritable.
Choice C rationale
The second stage of labor begins when the cervix is fully dilated and ends with the delivery of the baby. The contractions are strong, occurring every 2-3 minutes and lasting about 45-90 seconds. The client feels a strong urge to push during contractions.

A. Maternal blood glucose 63 mg/dL B. Enhanced production of fetal lung surfactant C. Weakened uterine contractions D. Fetal heart rate 100/min .

Correct Answer is C

Explanation

Choice A rationale
Terbutaline does not typically cause a decrease in maternal blood glucose levels. It is a medication used to relax the muscles in the uterus to prevent premature labor.
Choice B rationale
Terbutaline does not enhance the production of fetal lung surfactant. It is used to relax the muscles in the uterus to prevent premature labor.
Choice C rationale
Weakened uterine contractions are an expected finding in a client who has received terbutaline. Terbutaline is a tocolytic medication, which means it works to inhibit uterine contractions in order to prevent or halt preterm labor.
Choice D rationale
Terbutaline does not typically cause a decrease in fetal heart rate. It is used to relax the muscles in the uterus to prevent premature labor.

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A nurse is discharging a child who has recovered from an acute crisis episode of sickle cell anemia. What instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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