A nurse is assisting in the care of a child in the pediatrician's office.

Exhibits
Which of the following symptoms is the child at risk of developing?

bone marrow failure

hypernatremia

malabsorption

chronic respiratory infections

excessive weight gain

Answer and Explanation

Correct Answer : C,D

Rationale:

• Chronic respiratory infections: A positive sweat chloride test confirms cystic fibrosis, a condition characterized by thick mucus that obstructs airways, leading to persistent cough, wheezing, and a high risk of recurrent lung infections due to impaired mucus clearance.

• Malabsorption: Cystic fibrosis affects the pancreas by blocking enzyme flow needed for digestion. This results in poor nutrient absorption, causing symptoms like excessive hunger, weight loss despite eating well, and abdominal distension, all of which are evident in this child.

• Bone marrow failure: There are no signs of pancytopenia, anemia, or infection susceptibility that would suggest bone marrow dysfunction. Cystic fibrosis does not typically impact hematopoietic function directly.

• Hypernatremia: Although cystic fibrosis can lead to salt imbalances due to abnormal chloride transport, hypernatremia is not commonly a presenting concern unless there's severe dehydration, which is not evident here.

• Excessive weight gain: The child is losing weight despite increased appetite. Malabsorption from pancreatic insufficiency prevents weight gain in cystic fibrosis, making excessive weight gain an unlikely risk.

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Correct Answer is A

Explanation

Rationale:

A. Increased urinary output: Diuresis is expected within the first 12 to 24 hours postpartum as the body eliminates excess fluid retained during pregnancy. Increased urinary output helps reduce blood volume and interstitial fluid accumulated during gestation, making this a normal finding.

B. Temperature 38.2° C (100.0° F): A slight elevation in temperature can occur postpartum due to dehydration or breast engorgement, but 38.2°C is at the upper limit and may suggest infection if persistent. Therefore, it should be monitored rather than considered a typical finding.

C. Presence of lochia serosa: At 12 hours postpartum, lochia rubra, which is bright red and contains blood and tissue debris, is expected. Lochia serosa, which is pink or brown and more serous, typically appears around day 4 postpartum.

D. Deep tendon reflexes 3+: Reflexes of 3+ are slightly brisker than normal and may indicate neurological irritability or preeclampsia if seen with other symptoms. A normal postpartum reflex should be 2+, so this finding requires further evaluation.

A. Remove the client's dentures from their mouth before rigor mortis begins B. Turn on all the lights in the room before the family views the client's body. C. Ask the client's family about cultural or religious practices regarding postmortem care D. Position the client's bed flat without a pillow under their head.

Correct Answer is C

Explanation

Rationale:

A. Remove the client's dentures from their mouth before rigor mortis begins: Removing dentures is generally done after rigor mortis to maintain the natural appearance of the face for viewing. Premature removal can alter facial structure and affect family perceptions.

B. Turn on all the lights in the room before the family views the client's body: Bright lighting may be uncomfortable or overwhelming for grieving family members. Soft, gentle lighting is usually preferred to create a calm and respectful environment.

C. Ask the client's family about cultural or religious practices regarding postmortem care: Different cultures and religions have specific rituals and practices for caring for the deceased. Inquiring about these preferences ensures that the nurse respects the family’s beliefs and supports culturally sensitive care.

D. Position the client's bed flat without a pillow under their head: After death, the head of the bed should be slightly elevated (e.g., 15-30 degrees) to prevent blood from pooling in the face and causing discoloration, which can be distressing for the family.

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A nurse is assisting in the care of a child in the pediatrician's office. Exhibits Which of the following symptoms is the child at risk of developing?

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Naxlex Comprehensive Predictor Exams

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A nurse is assisting in the care of a child in the pediatrician's office.

Exhibits
Which of the following symptoms is the child at risk of developing?