A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

Elevated blood pressure.

Rapid, irregular heart rate.

Swollen feet and ankles.

Blood-tinged sputum.

Answer and Explanation

The Correct Answer is D

Choice A reason: Elevated blood pressure is a concern but not as immediately threatening as some other symptoms associated with mitral valve stenosis.

Choice B reason: A rapid, irregular heart rate could indicate atrial fibrillation, which is common in mitral valve stenosis, but it is not as urgent as blood-tinged sputum.

Choice C reason: Swollen feet and ankles suggest fluid retention, which is a concern in mitral valve stenosis but not as immediate as hemoptysis.

Choice D reason: Blood-tinged sputum indicates hemoptysis, which can be a sign of pulmonary edema or other serious complications requiring immediate intervention. This symptom is the most urgent and could signify a potentially life-threatening condition.

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Correct Answer is C

Explanation

Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.

Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.

Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.

Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.

A. Monitor for fever B. Give only clear liquids for several days C. Avoid any kind of bath or shower D. Keep a pressure dressing on the site for one week E. Alert the physician if the site bleeds or swells F. The child may take ibuprofen for pain

Correct Answer is ["A","E","F"]

Explanation

Choice A reason: Monitoring for fever is essential after cardiac procedures like the one described. Fever can be a sign of infection, which is a risk following any invasive procedure. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C) for a typical child, but it can be slightly lower in the morning and higher in the late afternoon and evening.
Choice B reason: There is no need to restrict the child to clear liquids for several days unless specifically instructed by the physician for a particular reason. After cardiac catheterization, patients are usually encouraged to resume their normal diet as tolerated to promote recovery unless there are other concerns that warrant dietary restrictions1.
Choice C reason: Avoiding baths or showers is generally recommended immediately after cardiac catheterization to prevent infection at the catheter insertion site. However, this restriction is usually only for a few days, not indefinitely. The site needs to be kept dry and clean until it has sufficiently healed.
Choice D reason: Keeping a pressure dressing on the site for one week is not typically necessary. The dressing is usually checked and changed by healthcare professionals, and the site is monitored for healing. The dressing may be removed after a certain period, often before one week, as long as there are no signs of bleeding or infection.
Choice E reason: Alerting the physician if the site bleeds or swells is crucial. Swelling or bleeding can indicate complications such as infection or hematoma formation. Parents should be instructed to look for any signs of abnormal discharge, redness, or increased pain, which could signify an infection.
Choice F reason: The child may take ibuprofen for pain, but it should be under the guidance of a physician. Ibuprofen is an NSAID that can help with pain and inflammation. However, it’s important to use the correct dosage and to ensure it doesn’t interfere with any other medications the child may be taking.

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A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is C

Explanation

Patient Data Exhibits The nurse educates the parents on post discharge care for the child. What should the nurse include in post discharge care education? Select all that apply.

Correct Answer is ["A","E","F"]

Explanation

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