Which are the most serious complications for a child diagnosed with Kawasaki Disease?
Coronary thrombosis.
Coronary stenosis.
Decreased sedimentation rate.
Coronary artery aneurysm.
Hypocoagulability.
Correct Answer : A,D
Choice A rationale
Coronary thrombosis is a life-threatening complication where a blood clot forms in a coronary artery, leading to a myocardial infarction. Kawasaki disease causes inflammation of the blood vessels (vasculitis), which can damage the endothelium of the coronary arteries. This damage creates a site for clot formation, which can occlude blood flow and cause severe myocardial ischemia or death.
Choice B rationale
Coronary stenosis is a narrowing of the coronary arteries. While it can be a long-term complication of Kawasaki disease, leading to restricted blood flow, it is generally considered a less immediate and life-threatening complication than an acute thrombosis or aneurysm. The stenosis itself is not the most serious acute event, although it does increase the risk of later cardiac events.
Choice C rationale
A decreased sedimentation rate, or ESR, would not be a complication. In fact, an elevated ESR is a hallmark of the acute inflammatory process in Kawasaki disease. The ESR measures the rate at which red blood cells settle, which is increased during inflammation due to the presence of acute-phase proteins. A decreased ESR would indicate a reduction in inflammation, not a complication.
Choice D rationale
Coronary artery aneurysm is a primary serious complication of Kawasaki disease. The vasculitis can weaken the arterial walls, leading to the formation of aneurysms. These aneurysms can rupture, causing a hemorrhage, or they can be the site of a thrombosis. Aneurysms are a significant source of long-term morbidity and mortality in children with the disease.
Choice E rationale
Hypocoagulability, or a reduced ability to form blood clots, is not a complication of Kawasaki disease. In the acute phase, patients are more likely to be in a hypercoagulable state due to the systemic inflammatory response. This increased risk of clotting is what makes coronary thrombosis a significant concern, not hypocoagulability
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. The primary concern is the potential for umbilical cord prolapse due to the gush of amniotic fluid, which can compromise fetal oxygenation. The fluid rate can be addressed after ensuring fetal well-being.
Choice B rationale
Providing a clean gown and linens is important for client comfort and hygiene but is not a priority over assessing fetal status. A change in linens can be done after the immediate safety of the fetus is confirmed, as a compromised fetal heart rate requires immediate intervention.
Choice C rationale
Assessing the fetal heart rate is the highest priority action after an amniotomy. The sudden release of amniotic fluid increases the risk of an umbilical cord prolapse, where the cord can be compressed, leading to a sudden decrease in fetal oxygenation and an emergent bradycardia. The normal fetal heart rate is 110-160 beats per minute.
Choice D rationale
Assisting the client with perineal hygiene is an important comfort measure and infection prevention strategy, but it is not the most critical and immediate action. The potential for a sudden, life-threatening change in fetal status due to cord prolapse takes precedence over hygiene.
Correct Answer is D
Explanation
Choice A rationale
Assessing for the need for pain medication is not appropriate at 10 cm dilation. At this stage, the client is in the second stage of labor, which is characterized by pushing and the birth of the baby. The use of pain medication at this point could potentially suppress the mother’s urge to push and prolong labor, so it is generally not a priority.
Choice B rationale
Administering oxytocin is not the correct action. Oxytocin is a hormone used to induce or augment labor. A client who has reached 10 cm dilation is in the second stage of labor and no longer needs augmentation. Administering oxytocin at this stage could increase the risk of uterine hyperstimulation and fetal distress.
Choice C rationale
The client's dinner is irrelevant at this stage of labor. A client at 10 cm dilation is in the second stage of labor, which is the pushing phase leading to birth. Oral intake is typically restricted during active labor to prevent the risk of aspiration if general anesthesia is required, and a meal is not a consideration.
Choice D rationale
When the client reaches 10 cm dilation, the cervix is fully dilated and effaced, signifying the end of the first stage of labor. This is the transition to the second stage of labor, which involves pushing and delivery. The nurse's next action is to prepare for this stage by setting up sterile equipment, positioning the client, and providing coaching for pushing efforts.
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