RATIONALE:
HF is the inability of the heart to pump a sufficient amt of blood to meet the
O2 and metabolic needs of the body. The early SSx of HF include
tachycardia, tachypnea, profuse scalp sweating, fatigue & irritability, sudden
weight gain, and resp distress. A cough may occur in HF as a result of
mucosal swelling & irritation, but is not an early sign. Pallor may be noted in
an infant w/ HF, but is not an early sign.
The clinic nurse reviews the record of an infant and notes that the health
care provider has documented a diagnosis of suspected Hirschsprung's
disease. The nurse reviews the assessment findings documented in the
record, knowing that which sign most likely led the mother to seek health
care for the infant?
RATIONALE:
Hirschsprung's disease is a congenital anomaly aka congenital aganglionosis
or aganglionic megacolon. It occurs as the result of an absence of ganglion
cells in the rectum and other areas of the affected intestine. Chronic
constipation beginning in the 1st month of life and resulting in pellet-like or
ribbon-like stools that are foul smelling is a SSx of this disorder. Delayed
passage or absence of meconium stool in the neonatal period is also a SSx.
Bowel obstruction, especially in the neonatal period; abdominal pain and
distension; and FTT are also SSx.
An infant has just returned to the nursing unit after surgical repair of a cleft
lip on the right side. The nurse should place the infant in which best position
at this time?
,1.Prone position
2.On the stomach
3.Left lateral position
4.Right lateral position - CORRECT ANSWERS-3. left lateral position
RATIONALE:
A cleft lip is a congenital anomaly that occurs as a result of failure of soft
tissue or bone structure to fuse during embryonic development. After cleft lip
repair, the RN avoids positioning an infant on the side of the repair or in the
prone position bc these positions can cause rubbing of the surgical site on
the mattress. The RN positions the infent on the side lateral to repair or on
the back upright and positions the infant to prevent airway obstruction by
secretions, blood, or the tongue.
The nurse reviews the laboratory results for a child with a suspected
diagnosis of rheumatic fever, knowing that which laboratory study would
assist in confirming the diagnosis?
1.Immunoglobulin
2.Red blood cell count
3.White blood cell count
4.Anti-streptolysin O titer - CORRECT ANSWERS-4. anti-streptolysin O titer
RATIONALE:
Rheumatic fever is an inflammatory autoimmune disease that affects the CT
of the heart, joints, skin (SQ tissues), BV, and CNS. A Dx of rheumatic fever is
confirmed by the presence of 2 major manifestations or 1 major and 2 minor
manifestations from the Jones criteria. In addition, evidence of a recent strep
infection is confirmed by a + anti-streptolysin O titer, streptozyme assay, or
anti-DNase B assay.
On assessment of a child admitted with a diagnosis of acute-stage Kawasaki
disease, the nurse expects to note which clinical manifestation of the acute
stage of the disease?
1.Cracked lips
2.Normal appearance
3.Conjunctival hyperemia
4.Desquamation of the skin - CORRECT ANSWERS-3. conjunctival hyperemia
RATIONALE:
Kawasaki disease, aka mucocutaneous lymph node syndrome, is an acute
systemic inflammatory illness. In the acute stage, the child has a fever,
conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of
the cervical lymph nodes. In the subacute stage, cracking lips and fissures,
, desquamation of the skin on the tips of the fingers and toes, joint pain,
cardiac manifestations, and thromobocytosis occur. In the convalescent
stage, the child appears normal, but SSx of inflammation may be present
The mother of a child being discharged after heart surgery asks the nurse
when the child will be able to return to school. Which is the most appropriate
response to the mother?
1."The child may return to school in 1 week."
2."The child will not be able to return to school during this academic year."
3."The child may return to school in 1 week but needs to go half-days for the
first 2 weeks."
4."The child may return to school in 3 weeks but needs to go half-days for
the first few days." - CORRECT ANSWERS-4. "The child may return to school
in 3 weeks but needs to go half-days for the 1st few days"
RATIONALE:
After heart surgery, the child may be able to return to school in 3 weeks but
needs to go half-days for the 1st few days. The mother also should be told
that the child cannot participate in PE for 2 months.
Prostaglandin E1 is prescribed for a child with transposition of the great
arteries. The mother of the child is a registered nurse and asks the nurse
why the child needs the medication. What is the most appropriate response
to the mother about the action of the medication?
1.Prevents blue (tet) spells
2.Maintains adequate cardiac output
3.Maintains an adequate hormonal level
4.Maintains the position of the great arteries - CORRECT ANSWERS-2.
maintains adequate CO
RATIONALE:
A child with transposition of the great arteries may receive prostaglandin E1
temporarily to increased blood mixing if systemic and pulmonary mixing is
inadequate to maintain adequate CO.
The nurse is assessing a newborn with heart failure before administering the
prescribed digoxin. In reviewing the laboratory data, the nurse notes that the
newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical
heart rate of 90 beats/min. The mother also tells the nurse that the newborn
just vomited her formula. Which intervention should the nurse take?
1.Retake the apical pulse.
2.Administer the medication.
3.Withhold the medication for 1 hour.
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