The nurse is assessing a 6-year-old child with glomerulonephritis. Which finding should the nurse respond to first?

Periorbital edema

Blood pressure 142/90

Pain on urination

Amber-colored urine

Answer and Explanation

The Correct Answer is B

Choice A reason: Periorbital edema is common in glomerulonephritis due to fluid retention from reduced glomerular filtration. While concerning, it is not immediately life-threatening compared to severe hypertension, which can cause organ damage, making this a lower-priority finding requiring monitoring but not urgent intervention.

Choice B reason: A blood pressure of 142/90 in a 6-year-old indicates severe hypertension, a medical emergency in glomerulonephritis due to fluid overload and renal dysfunction. It risks organ damage (e.g., brain, heart), requiring immediate intervention to lower pressure, making this the highest-priority finding for the nurse to address.

Choice C reason: Pain on urination suggests a urinary tract infection or irritation, not a primary feature of glomerulonephritis, which typically involves hematuria and proteinuria. While discomfort needs attention, it is less urgent than hypertension, which poses immediate risks, making this a lower-priority finding.

Choice D reason: Amber-colored urine in glomerulonephritis reflects hematuria or concentrated urine due to reduced renal function. While indicative of the condition, it is not immediately life-threatening compared to severe hypertension, which can cause acute organ damage, making this a lower-priority finding for immediate response.

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Correct Answer is D

Explanation

Choice A reason: Stuttering involves repetition or prolongation of sounds, not omitting words for brevity. Telegraphic speech, where toddlers use short phrases like “want go potty,” is normal at age 3, reflecting developmental language simplification, not a fluency disorder like stuttering, making this an incorrect response.

Choice B reason: Echolalia is the repetition of others’ words, often seen in autism, not the use of short, functional phrases. The described speech, “want go potty,” is telegraphic, a normal toddler pattern, not echolalia requiring correction, making this an inaccurate response for the observed speech pattern.

Choice C reason: Telegraphic speech is normal in 3-year-olds, not a developmental delay. Consulting a speech therapist is unnecessary unless other language milestones are delayed. The described speech pattern, using key words without connectors, is typical for this age, making this response incorrect and overly interventionist.

Choice D reason: Telegraphic speech, common in 3-year-olds, involves short phrases with essential words (e.g., “want go potty”), omitting articles or connectors. This is a normal developmental stage as toddlers simplify language to communicate effectively, aligning with the described speech pattern, making this the correct response.

A. The child is currently taking antibiotics for otitis media B. The child has a congenital immunodeficiency C. The child has a cough and a temperature of 37.7°C (99.9°F) D. The child’s temperature after the last set of immunizations was 38.3°C (101°F)

Correct Answer is B

Explanation

Choice A reason: Antibiotics for otitis media do not contraindicate MMR vaccination, as antibiotics treat bacterial infections and do not interfere with the immune response to this live attenuated vaccine. The MMR can be safely administered in children with mild bacterial infections, making this an incorrect contraindication.

Choice B reason: Congenital immunodeficiency (e.g., severe combined immunodeficiency) is a contraindication for MMR, a live attenuated vaccine. Such conditions impair the immune system’s ability to control the attenuated virus, risking severe infection. Avoiding MMR in these children prevents life-threatening complications, making this the correct contraindication for the vaccine.

Choice C reason: A mild cough and temperature of 37.7°C (99.9°F) indicate a minor illness, which is not a contraindication for MMR vaccination. Live vaccines like MMR can be safely given during mild infections, as they do not significantly impair the immune response, making this an incorrect choice.

Choice D reason: A fever of 38.3°C (101°F) after previous immunizations is a common, transient reaction and not a contraindication for MMR. It does not indicate an immune deficiency or hypersensitivity that would prevent future vaccinations, making this an incorrect choice for withholding the MMR vaccine.

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The nurse is assessing a 6-year-old child with glomerulonephritis. Which finding should the nurse respond to first?

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