A nurse is attending to an 8-year-old child diagnosed with acute rheumatic fever. What should be the nurse’s immediate priority assessment after admission?
Identifying the level of parental anxiety related to the diagnosis
Auscultating the rate and characteristics of the child’s heart sounds
Using a pain-rating tool to evaluate the severity of the joint pain
Assessing the client’s erythematous rash
The Correct Answer is B
Choice A rationale
While it’s important to assess the level of parental anxiety related to the diagnosis, it’s not the immediate priority. The child’s physical health needs to be stabilized first.
Choice B rationale
This is the correct answer. Auscultating the rate and characteristics of the child’s heart sounds is the immediate priority. Acute rheumatic fever can lead to serious cardiac complications, so it’s crucial to monitor the child’s heart function closely.
Choice C rationale
While assessing the severity of joint pain is important in managing the child’s comfort, it’s not the immediate priority. The child’s heart function needs to be assessed first.
Choice D rationale
While assessing the client’s erythematous rash is part of the overall assessment of a child with acute rheumatic fever, it’s not the immediate priority. The child’s heart function needs to be assessed first.
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Correct Answer is B
Explanation
Choice A rationale
Gestational hypertension is characterized by high blood pressure that develops after 20 weeks of pregnancy and typically resolves within a few weeks postpartum. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of kidney damage.
However, Sarah’s condition does not fit this description because her blood pressure has been consistently high since she was 26, not just during pregnancy.
Choice B rationale
Chronic hypertension refers to high blood pressure before pregnancy or early in pregnancy. Eclampsia is a severe form of preeclampsia that causes seizures. Given Sarah’s history of consistent high blood pressure since age 26 and her recent seizure at 32 weeks’ gestation, this choice fits her condition.
Choice C rationale
Gestational hypertension refers to high blood pressure that begins during pregnancy. Eclampsia is a severe form of preeclampsia that causes seizures. However, Sarah’s high blood pressure did not begin during pregnancy, making this choice incorrect.
Choice D rationale
Chronic hypertension refers to high blood pressure before pregnancy or early in pregnancy. HELLP Syndrome (Hemolysis, Elevated Liver enzyme levels, and Low Platelet levels) is a serious health condition that can affect pregnant women3. However, Sarah’s symptoms do not indicate HELLP Syndrome, making this choice incorrect.
Correct Answer is D
Explanation
Step 1 is: Calculate the Apgar score based on the given vital signs. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color.
Step 2 is: Assign points for each criterion. For heart rate of 160 bpm, assign 2 points. For good, vigorous respiratory effort, assign 2 points. For active movement and well-flexed muscle tone, assign 2 points. For crying with stimulation of soles of feet (reflex irritability), assign 2 points. For body pink but feet and hands cyanotic (color), assign 1 point.
Step 3 is: Add up the points. 2 (heart rate) + 2 (respiratory effort) + 2 (muscle tone) + 2 (reflex irritability) + 1 (color) = 9 points. So, the correct Apgar score for this newborn is 9.
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