A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?

"Haven't you been feeding according to recommended daily allowances for children?"

"Does your child seem mentally slower than his peers also?"

"You should not worry about the growth tables. They are only averages for children."

"The smaller size is probably due to the heart disease."

Answer and Explanation

The Correct Answer is D

A. "Haven't you been feeding according to recommended daily allowances for children?": This response implies blame and lacks sensitivity. It doesn't acknowledge the child’s underlying medical condition that may affect growth.

B. "Does your child seem mentally slower than his peers also?": Intellectual development is unrelated to height/weight percentile in children with congenital heart disease unless there are neurological complications, which haven't been indicated.

C. "You should not worry about the growth tables. They are only averages for children.": While growth charts are averages, they are clinically significant, especially for identifying underdevelopment in children with chronic illnesses.

D. "The smaller size is probably due to the heart disease.": Chronic hypoxia and increased metabolic demands in congenital heart disease often contribute to poor weight gain and growth delay, making this the most informative and empathetic response.

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

Explanation

Rationale for correct findings:

Fasting 1-hour glucose screen: 164 mg/dL (9.1 mmol/L): The fasting glucose of 164 mg/dL is elevated, indicating impaired glucose metabolism, which suggests the possibility of gestational diabetes.
3-hour glucose tolerance test: Fasting blood sugar 168 mg/dL (9.3 mmol/L): The fasting blood sugar of 168 mg/dL is above the normal threshold of 140 mg/dL, reinforcing the suspicion of gestational diabetes.
2-hour postprandial glucose: 220 mg/dL (12.2 mmol/L): A postprandial glucose level of 220 mg/dL is significantly above the normal limit of 140 mg/dL, further indicating gestational diabetes.
Fourth child with macrosomia: 9 pounds (4.08 kg) at 41 weeks gestation: Macrosomia is often associated with gestational diabetes. The fourth child weighing 9 pounds suggests the possibility of undiagnosed gestational diabetes during the previous pregnancy, which could be recurring in the current pregnancy.

Rationale for incorrect Findings:

Client is at 28 weeks and has been receiving prenatal care since 8 weeks gestation: The client’s consistent prenatal care since 8 weeks indicates early and regular monitoring, reducing the likelihood of other major complications.

A. Monitor collection container and replace when full. B. Encourage frequent use of the incentive spirometer. C. Assess area around chest tube for subcutaneous emphysema. D. Keep tubing loosely coiled below the level of the chest. E. Verify air bubbling present in the water seal chamber.

Correct Answer is ["B","C","D"]

Explanation

A. Monitor collection container and replace when full: The nurse should monitor the collection container to ensure it doesn't become full, as this could cause backflow into the pleural cavity. Replacing it when full is essential to maintain proper drainage.

B. Encourage frequent use of the incentive spirometer: Using the incentive spirometer helps prevent atelectasis and pneumonia by promoting lung expansion. It is important for postoperative recovery to maintain good respiratory function.

C. Assess area around chest tube for subcutaneous emphysema: Subcutaneous emphysema can occur if air leaks into the tissues around the chest tube. The nurse should check for this condition as it could indicate complications like an air leak or pneumothorax.

D. Keep tubing loosely coiled below the level of the chest: The tubing should be positioned below the chest to facilitate gravity drainage. Keeping it loosely coiled ensures that fluid and air drain efficiently without backflow.

E. Verify air bubbling present in the water seal chamber: Continuous bubbling in the water seal chamber is not expected and may indicate an air leak. Intermittent bubbling may be normal if the lung is still re-expanding, but ongoing bubbling should be reported, not simply verified.

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A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse is caring for a client who underwent a right lobectomy for lung cancer 24 hours ago and has a single chest tube on the right side. Which intervention(s) should the nurse plan to implement? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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