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 A

Explanation

Choice A rationale
Cervical dilation is a key sign that labor has begun. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a physical change that can be measured during a pelvic exam.
Choice B rationale
Pain above the umbilicus is not typically a sign of labor. During labor, contractions are usually felt as a tightening or cramping in the lower abdomen or back.
Choice C rationale
Brownish vaginal discharge can occur during pregnancy and is not necessarily a sign of labor. If the discharge is heavy, or accompanied by other symptoms such as pain or cramping, it should be evaluated by a healthcare provider.
Choice D rationale
The presence of amniotic fluid in the vaginal vault, also known as “water breaking,” can be a sign that labor is imminent. However, it does not confirm that labor has begun, as it can occur before the onset of contractions and cervical dilation.

A. Deep tendon reflexes of +1 B. Blood pressure 148/98 mm Hg C. 1+ pitting sacral edema D. 3+ protein in the urine .

Correct Answer is A

Explanation

Choice A rationale
Deep tendon reflexes of +1 are not consistent with preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of kidney damage. One of the symptoms can be hyperreflexia, or overly active reflexes, not diminished reflexes.
Choice B rationale
Blood pressure of 148/98 mm Hg is consistent with preeclampsia, as one of the defining features of preeclampsia is high blood pressure.
Choice C rationale
1+ pitting sacral edema is consistent with preeclampsia. Edema, or swelling, is a common symptom of preeclampsia.
Choice D rationale
3+ protein in the urine is consistent with preeclampsia. One of the defining features of preeclampsia is the presence of excess protein in urine (proteinuria), which indicates kidney problems. Deep vein thrombosis Deep vein thrombosis Explore

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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 midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

Correct Answer is A

Explanation

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Correct Answer is A

Explanation

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