The practical nurse (PN) is caring for an infant with ambiguous genitalia and congenital adrenal hyperplasia.
Which intervention should the PN prioritize?
Monitor serum electrolytes.
Check for hypothermia.
Assess for urinary tract infection.
Record daily weights.
The Correct Answer is A
Choice A rationale
Monitoring serum electrolytes is the top priority for an infant with congenital adrenal hyperplasia (CAH). This condition involves an enzymatic defect that impairs cortisol and aldosterone synthesis, leading to salt wasting due to insufficient aldosterone. This can cause life-threatening hyponatremia and hyperkalemia, requiring urgent intervention. Normal ranges are typically sodium 135-145 mEq/L and potassium 3.5-5.0 mEq/L.
Choice B rationale
Checking for hypothermia is important for any neonate or infant, as they have immature thermoregulation. While a general nursing intervention, it is not the most specific or life-threatening concern directly related to the pathophysiology of congenital adrenal hyperplasia, which primarily involves electrolyte imbalances.
Choice C rationale
Assessing for urinary tract infection is a relevant general health assessment, especially in infants with ambiguous genitalia, due to potential anatomical variations. However, while important for overall health, it does not address the immediate, life-threatening metabolic derangements associated with congenital adrenal hyperplasia.
Choice D rationale
Recording daily weights is crucial for assessing fluid balance in infants, particularly those at risk for dehydration or fluid retention. While important for monitoring overall health and fluid status, it is secondary to the critical need to monitor and correct acute electrolyte imbalances that can rapidly become life-threatening in CAH.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Acute otitis media is an infection of the middle ear, specifically the air-filled space behind the eardrum. This infection typically results from bacterial or viral invasion, often following an upper respiratory tract infection. It leads to inflammation and fluid accumulation, causing pain and hearing impairment.
Choice B rationale
A drainage out of the outer ear, known as otorrhea, can be a symptom of various ear conditions, including otitis externa (swimmer's ear) or a perforated eardrum with middle ear infection, but it is not the definition of acute otitis media itself.
Choice C rationale
An infection of the inner and outer ear would encompass otitis interna (labyrinthitis) and otitis externa. Acute otitis media specifically refers to the middle ear. While infections can spread, this description is not precise for acute otitis media.
Choice D rationale
A defect of the inner ear relates to structural or functional abnormalities of the cochlea or vestibular system, leading to conditions like sensorineural hearing loss or balance issues. This is a congenital or acquired structural problem, not an infection like acute otitis media.
Correct Answer is B
Explanation
Choice A rationale
While nausea can occur from analgesics used during labor, and solid foods might exacerbate it, this is not the primary or most critical reason for withholding them. The major concern is related to potential aspiration during anesthesia or an emergency. Analgesics can also cause gastric stasis, but the aspiration risk remains paramount.
Choice B rationale
If general anesthesia becomes necessary during labor, the risk of pulmonary aspiration of gastric contents is significantly increased due to delayed gastric emptying and relaxation of the gastroesophageal sphincter. Aspiration pneumonitis can lead to severe respiratory complications. Therefore, withholding solid foods minimizes this critical risk.
Choice C rationale
Gastric emptying time actually increases during labor, meaning food remains in the stomach for a longer duration. This prolonged retention of gastric contents heightens the risk of aspiration if the client requires general anesthesia or experiences emesis. Reduced peristalsis contributes to this extended emptying time.
Choice D rationale
Autonomic nervous system stimulation, specifically sympathetic activation, during labor leads to a decrease in gastrointestinal motility and peristalsis. This physiological response contributes to delayed gastric emptying, increasing the volume of gastric contents and subsequently elevating the risk of aspiration.
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