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 ["25"]
Explanation
Step 1 is: Subtract the dry diaper weight from the wet diaper weight to find the weight of the urine. 75 grams - 50 grams = 25 grams.
Step 2 is: Convert the weight of the urine from grams to milliliters, as 1 gram of urine is approximately equal to 1 mL. 25 grams = 25 mL. The urine output is 25 mL.
Correct Answer is D
Explanation
Choice A rationale
An acceleration is a visually apparent abrupt increase in the fetal heart rate above the baseline. For a 38-week fetus, an acceleration is defined as an increase of 15 beats per minute or more above the baseline, lasting 15 seconds or more but less than 2 minutes. The given finding of 10 seconds does not meet this criterion.
Choice B rationale
While fetal movement often accompanies accelerations, documenting "fetal movement" alone is insufficient. The nonstress test specifically assesses the fetal heart rate response to movement, and the critical finding to document relates to the FHR pattern itself, not just the presence of movement.
Choice C rationale
A positive tracing in obstetrics typically refers to a positive contraction stress test, which indicates late decelerations and is an abnormal finding. This terminology is not applicable to a nonstress test, where the terms "reactive" or "nonreactive" are used to describe the findings.
Choice D rationale
A nonreactive pattern on a nonstress test for a 38-week fetus is defined by the absence of two or more accelerations (15 bpm above baseline for at least 15 seconds) within a 20-minute period. The observed FHR increases lasting only 10 seconds do not meet the duration criteria for reactivity.
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