A 2-month-old infant contracts a disease through vertical transmission.
Which situation should the nurse investigate further to ascertain how the infant might have been exposed to the disease?

Answer and explanation

The correct answer is Choice B.

Choice A rationale

Rechecking the client’s vital signs in 30 minutes may not be the most appropriate action in this situation. The client is showing signs of possible complications such as infection (elevated

temperature, malaise) and referred pain in the shoulder, which could indicate diaphragmatic irritation. These symptoms, along with the client’s recent surgery, suggest that immediate medical attention may be necessary.

Choice B rationale

Having the client transported via ambulance to the hospital is the most appropriate action. The client’s symptoms suggest possible complications that require immediate medical attention.

Abdominal tenderness and shoulder pain could indicate a serious condition such as a perforation or infection. The elevated heart rate and low blood pressure could suggest sepsis or shock. Immediate medical evaluation and treatment are necessary.

Choice C rationale

Determining the client’s current oxygen saturation rate is important, but it is not the most immediate need. While this information could provide additional data about the client’s condition, it does not address the potential seriousness of the client’s symptoms. The client needs immediate medical attention.

Choice D rationale

Instructing the client to drive to the hospital for admission is not the best choice. Given the client’s symptoms and recent surgery, it would be safer for the client to be transported by ambulance. This would ensure that the client receives immediate medical attention and that the client’s condition can be monitored during transport.

Answer and explanation

The correct answer is Choice D.

Choice A rationale

Increasing physical activity is a key component of weight loss. It helps to burn calories, build muscle, and boost metabolism. However, physical activity alone may not be sufficient for weight loss. It’s also important to consider dietary habits.

Choice B rationale

Improving diet is another crucial aspect of weight loss. This can involve eating more fruits, vegetables, and whole grains, reducing the intake of processed foods and sugary drinks, and watching portion sizes. However, diet alone may not be enough for weight loss, and it’s also important to incorporate physical activity.

Choice C rationale

Reducing portion sizes can help to decrease calorie intake, which can contribute to weight loss. However, portion control alone may not lead to weight loss if the individual is not consuming a balanced diet or if they are not physically active.

Choice D rationale

All of the above strategies - increasing physical activity, improving diet, and reducing portion sizes - are important for weight loss. They work together to create a calorie deficit, which is necessary for weight loss. It’s also important to note that these strategies should be implemented as part of a sustainable lifestyle change, rather than a short-term diet.