Patient Data

Exhibits

The nurse is considering the client's acute condition while performing the admission assessment.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse determines that the client's symptoms are most likely caused by
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resulting in
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and
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Rationale for Correct Choices:

Cleft palate: The infant’s CT shows a V-shaped bony defect of the hard palate, bifid uvula, and a translucent midline zone in the soft palate, indicating a submucous cleft palate. These structural defects explain feeding difficulties, formula regurgitation through the nose, and associated complications.
Otitis media: Infants with cleft palate frequently develop middle ear infections due to impaired Eustachian tube function. The moderate bulging and erythema of the tympanic membranes, along with fussiness and ear-pulling, support otitis media as a current manifestation.
Occluded eustachian tubes: The palatal defect disrupts normal Eustachian tube drainage, leading to fluid accumulation and recurrent middle ear infections. This obstruction contributes to hearing issues and may worsen if untreated.

Rationale for Incorrect Choices

Subglottic stenosis: This condition involves narrowing below the vocal cords, causing stridor or respiratory distress. The infant has clear breath sounds and no airway compromise, making this diagnosis unlikely.
Congenital laryngeal web: A laryngeal web affects the voice and breathing rather than feeding, regurgitation, or ear infections. The infant shows no signs of airway obstruction or abnormal cry.
Hearing impairment: Hearing impairment is a potential long-term complication of recurrent otitis media, but there is no current evidence of hearing loss in this infant. Immediate management focuses on the infection and Eustachian tube obstruction.
Nasal regurgitation: While nasal regurgitation occurs due to the cleft palate, in this scenario it is a symptom rather than a separate condition. The main acute issues are otitis media and occluded Eustachian tubes.
Speech delays: Speech delays can develop later in infants with cleft palate due to impaired palatal function, but they are not present at this stage. The infant’s current assessment focuses on feeding and ear complications rather than speech development.
Poor weight gain: Although feeding difficulties can lead to growth issues over time, the immediate concern is otitis media and Eustachian tube obstruction. Weight issues are secondary and will require ongoing monitoring.

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Correct Answer is B

Explanation

Rationale:

A. Let the infant breastfeed: Breastfeeding stimulates oxytocin release, which can promote uterine contraction and help prevent postpartum hemorrhage. While beneficial, it is not the first action when active bleeding is observed.

B. Assess her blood pressure: Monitoring blood pressure is a priority when continuous bright red vaginal bleeding occurs after delivery. Assessing vital signs allows the nurse to determine the hemodynamic stability of the client and identify early signs of hypovolemic shock, guiding urgent interventions.

C. Massage the fundus vigorously: The fundus is already firm at the umbilicus, indicating effective uterine contraction. Vigorous massage is unnecessary and may cause discomfort or trauma without addressing the source of bleeding.

D. Apply ice pack to perineum: Ice packs are useful for perineal pain or swelling but do not control vaginal bleeding from uterine sources. This intervention does not address the priority concern of postpartum hemorrhage.

A. Obtain a booster for all immunizations as soon as possible. B. Obtain an injection of penicillin G 1000 units weekly. C. Keep the child away from other children and begin a home school program. D. Avoid exposure to chickenpox.

Correct Answer is D

Explanation

Rationale:

A. Obtain a booster for all immunizations as soon as possible: While immunizations are important, live vaccines may be contraindicated in children with AIDS depending on their immune status. Boosters should be given only under the guidance of a healthcare provider.

B. Obtain an injection of penicillin G 1000 units weekly: Routine prophylactic penicillin is not indicated for children with AIDS unless there is a specific underlying condition such as sickle cell disease.

C. Keep the child away from other children and begin a home school program: Isolation from peers is unnecessary and can negatively impact social and emotional development. Standard precautions and avoiding exposure to infectious illnesses are more appropriate.

D. Avoid exposure to chickenpox: Children with AIDS are immunocompromised and at high risk for severe complications from varicella infection. Teaching the family to avoid exposure to chickenpox and other infectious diseases is essential to protect the child’s health.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is developing a teaching plan for a school-aged child with AIDS. Which instruction should the nurse include in the teaching plan for the family of a school-aged child with AIDS?

Correct Answer is D

Explanation

How many mL of urine output should the nurse document for an infant's wet diaper weight of 85 grams compared to the dry diaper weight of 50 grams? (Enter numeric value only.)

Patient Data Exhibits The nurse is reviewing the client's admission information. Which signs or symptoms warrant immediate follow-up by the nurse? Select all that apply.

Patient Data Exhibits The nurse is performing an assessment on the toddler. For each assessment finding, click to indicate whether the findings from the assessment should be a concern or not a concern to the nurse. Each row must have only one response option selected.

The nurse is caring for a multiparous client who is in labor and observes a fetal heart rate (FHR) that decreases with the peak of a contraction and returns to baseline in 30 seconds. Which action should the nurse implement?

At 6-weeks gestation, the rubella titer of a client indicates she is nonimmune. When is the best time to administer a rubella vaccine to this client?

Patient Data Exhibits Which findings indicate an improvement in the client’s condition?

The parents of a 14-month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to these parents?