An 18-month-old girl is diagnosed as having atopic dermatitis.
When interviewing her parents, they describe the following care measures. Which one would lead you to think more health teaching is needed?
To dry lesions, the father applies alcohol to lesions daily.
To aid healing, the father applies hydrocortisone cream to the lesions.
After a bath, the mother applies Eucerin cream.
The mother gives her a daily bath without using soap.
The Correct Answer is A
Choice A rationale
Applying alcohol to the lesions of atopic dermatitis is contraindicated. Alcohol is a drying agent and can further irritate and damage the already compromised skin barrier. This action would worsen the skin condition and cause pain, indicating a need for health teaching on appropriate skin care measures for atopic dermatitis.
Choice B rationale
Applying hydrocortisone cream is an appropriate treatment for atopic dermatitis. Hydrocortisone is a corticosteroid that reduces inflammation and itching associated with the condition. It works by suppressing the immune response in the skin, which helps to alleviate the redness and irritation of the lesions.
Choice C rationale
Applying Eucerin cream, which is a moisturizer, after a bath is a beneficial practice. Moisturizers help to lock in water and restore the skin's barrier function, which is compromised in atopic dermatitis. This helps to reduce dryness, itching, and the frequency of flare-ups.
Choice D rationale
Giving a daily bath without using soap is a recommended practice. The goal is to avoid harsh soaps that can strip the skin of its natural oils, leading to dryness and irritation. Using a non-soap cleanser or simply bathing in plain water helps to maintain skin hydration and health
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Bright red lochia with large clots suggests uterine atony, which is a failure of the uterine muscles to contract properly. This indicates that the oxytocin is not effective in promoting uterine contraction, which is necessary to control postpartum bleeding. Uterine atony is a leading cause of postpartum hemorrhage, and this finding is a sign of an ongoing bleeding problem, not a sign of effective medication.
Choice B rationale
A firm fundus indicates the uterine muscles are contracting effectively, which compresses blood vessels and prevents excessive bleeding. Oxytocin is a synthetic analog of the naturally occurring hormone oxytocin, and it works by stimulating these smooth muscle contractions in the uterus. Therefore, a firm fundus is the desired therapeutic effect and indicates the medication is working as intended.
Choice C rationale
A boggy fundus signifies a relaxed, poorly contracted uterus. This allows for blood vessels to bleed freely, increasing the risk of postpartum hemorrhage. This is the opposite of the desired effect of oxytocin and indicates that the medication is not effectively promoting uterine contraction to control bleeding.
Choice D rationale
Absent lochia postpartum is not a normal finding and may indicate an issue such as uterine retention of placental fragments or a blood clot, or an abnormal uterine position. The normal progression of lochia (a vaginal discharge after childbirth) is a physiological process that should occur regardless of medication effectiveness. Absent lochia does not demonstrate a normal physiological response to oxytocin.
Correct Answer is C
Explanation
Choice A rationale
Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. This action is not directly related to the most critical and immediate potential complication of this procedure, which is a change in the fetal heart rate. The primary concern is the potential for umbilical cord prolapse, which can lead to fetal hypoxia.
Choice B rationale
Providing a clean gown and linens is important for client comfort and hygiene, but it is not the immediate priority. The nurse must first ensure the safety of the fetus by assessing for complications that can arise from the procedure, such as umbilical cord compression or prolapse, which can lead to fetal distress and requires immediate intervention.
Choice C rationale
The immediate priority after an amniotomy is to assess the fetal heart rate. The sudden release of amniotic fluid can cause the umbilical cord to prolapse and become compressed, leading to a rapid decrease in blood flow and oxygen to the fetus. This compression results in fetal bradycardia, a critical finding requiring immediate intervention to prevent fetal hypoxia and death.
Choice D rationale
Assisting the client to wash the perineum is a hygiene measure that can be performed after the immediate safety of the fetus has been established. It is not the priority action. The nurse must first rule out any life-threatening complications to the fetus, such as cord prolapse, which is a significant risk following the rupture of membranes.
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