Patient Data

Exhibits

The nurse is planning care for the client. Drag from Word Choices to complete the sentence.

The nurse is planning interventions to reduce the client's risk of
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Answer and Explanation

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

Rationale for Correct Choices

Aspiration: The submucous cleft palate and bifid uvula increase the risk of formula or saliva entering the airway during feeding. Interventions such as proper positioning and thickened feeds help reduce aspiration risk.
Pneumonia: Repeated aspiration or impaired clearance of secretions can lead to lower respiratory tract infections, including pneumonia. Monitoring respiratory status and providing prompt interventions are essential.
Hearing loss: Infants with cleft palate often have occluded Eustachian tubes, which can cause recurrent otitis media and subsequent conductive hearing loss. Early identification and referral to audiology are recommended.

Rationale for Incorrect Choices

Cognitive delay: While cleft palate may affect speech development, it does not directly cause cognitive delay. The infant’s neurodevelopment appears age-appropriate.
Poor vision: There is no clinical or physiological reason presented in the client's data to suggest a risk of poor vision. This is a non-related finding.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Assess deep tendon reflexes (DTRs) every 4 hours: Monitoring DTRs is essential to detect early signs of magnesium toxicity, but the frequency of assessment alone does not immediately prevent life-threatening complications.

B. Provide a quiet environment with subdued lighting: A calm environment helps reduce maternal stress and may support labor progression, but it does not address the primary safety concern associated with magnesium sulfate therapy.

C. Have calcium gluconate immediately available: Calcium gluconate is the antidote for magnesium sulfate toxicity. Having it readily available is the highest priority because magnesium toxicity can rapidly depress neuromuscular and respiratory function, requiring immediate intervention.

D. Insert an indwelling urinary catheter with a urimeter to monitor hourly output: Monitoring urine output is important to assess renal function and magnesium excretion, but immediate availability of the antidote takes precedence in preventing life-threatening complications.

A. Grasp high on the sac and gently palpate downward to feel each testis present. B. Observe daily for the resolution of scrotal edema influenced by placental hormones. C. Palpate for a soft, mushy structure that is nontender and distinct from a normal testis. D. Perform transillumination of the scrotal sac to visualize a red glow of fluid around the testes.

Correct Answer is D

Explanation

Rationale:

A. Grasp high on the sac and gently palpate downward to feel each testis present: This technique helps assess for undescended testes but does not confirm the presence of fluid characteristic of a hydrocele.

B. Observe daily for the resolution of scrotal edema influenced by placental hormones: While some neonatal swelling may resolve spontaneously, observation alone does not provide an immediate method to differentiate a hydrocele from other causes of scrotal swelling.

C. Palpate for a soft, mushy structure that is nontender and distinct from a normal testis: Palpation can identify abnormalities in consistency, but distinguishing hydrocele fluid from testicular tissue is challenging without additional assessment methods like transillumination.

D. Perform transillumination of the scrotal sac to visualize a red glow of fluid around the testes: Transillumination is the most effective technique to confirm a hydrocele. A hydrocele allows light to pass through the fluid-filled sac, producing a red glow, which differentiate it from solid masses or other scrotal abnormalities.

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Patient Data Exhibits The nurse is planning care for the client. Drag from Word Choices to complete the sentence. The nurse is planning interventions to reduce the client's risk of dropdown, dropdown and dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mm Hg to 140/90 mm Hg. Which nursing protocol has the highest priority?

Correct Answer is C

Explanation

In assessing a 1-day-old male newborn, the nurse observes that the scrotal sac is large, swollen, smooth, and taut. Which assessment technique should the nurse perform to determine if the newborn has a hydrocele?

Correct Answer is D

Explanation

Patient Data Exhibits The nurse is evaluating the infant's progress and the parents' understanding of the condition. For each finding, click to indicate if it supports the interventions were effective or does not support the interventions were effective.

A 4-month-old has been admitted to the pediatric medical unit with respiratory syncytial virus (RSV). The infant demonstrates poor feeding and begins coughing frequently. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

Patient Data Exhibits Select the 4 topics the nurse will teach the parents to care for the toddler correctly.

Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs. (3,402 grams), weighs 7 lbs (3.175 grams) today?

The nurse is assessing a client at 29-weeks gestation. Which assessment method would provide the most accurate determination of fetal position?

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?

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.)

A nurse in the transition nursery is assigned to care for four recently delivered infants. Which infant should the nurse assess first? Reference Range: Blood glucose/neonate [30 to 60 mg/dL (1.7 to 3.3 mmol/L)]

Patient Data

Exhibits

The nurse is planning care for the client. Drag from Word Choices to complete the sentence.

The nurse is planning interventions to reduce the client's risk of
dropdown
,
dropdown
and
dropdown
.