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

Answer and Explanation

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
While reduced fetal oxygen supply can occur with hypertonic contractions and inadequate uterine relaxation, it’s not the primary adverse effect. The main concern is the impact on the progress of labor.
Choice B rationale
This is the correct answer. Inadequate uterine relaxation between hypertonic contractions can delay cervical dilation, slowing the progress of labor.
Choice C rationale
Prolonged labor is not typically associated with hypertonic contractions and inadequate uterine relaxation. In fact, these conditions can lead to a more rapid labor.
Choice D rationale
Increased maternal stress can occur with any labor complication, but it’s not the primary adverse effect of hypertonic contractions and inadequate uterine relaxation.

A. Client has had two prior pregnancies B. Client is currently pregnant with twins C. Client is at risk for miscarriage D. Client has had one full-term birth E. Client has one living child

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

Explanation

Choice A rationale
The G in GTPAL stands for gravida, which is the number of times an individual has conceived, including any current pregnancy. In this case, G3 means the client has had three pregnancies, which includes two prior pregnancies and the current one.
Choice B rationale
The client’s record does not indicate that she is currently pregnant with twins, making this choice incorrect.
Choice C rationale
The A in GTPAL stands for the number of abortions, which refers to all times the individual has lost a pregnancy before 20 weeks. In this case, A1 means the client has had one abortion, indicating a risk for miscarriage.
Choice D rationale
The T in GTPAL stands for term births, which refers to the number of times an individual has carried a pregnancy to at least 37 weeks of gestation and delivered. In this case, T1 means the client has had one full-term birth.
Choice E rationale
The L in GTPAL stands for living children. In this case, L1 means the client has one living child.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in labor who is experiencing incomplete uterine relaxation between hypertonic contractions. What adverse effect does the nurse recognize as a result of this contraction pattern?

Correct Answer is B

Explanation

A nurse in a prenatal clinic is caring for a client in the first trimester of pregnancy. The client’s health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply.)

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

Explanation

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