The nurse is assessing a child with acute glomerulonephritis who presents with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color.
Which additional finding should the nurse report to the healthcare provider?
Positive rapid strep test of oropharynx.
Blood pressure 88/50 mmHg.
Maculopapular rash over trunk of body.
Weight loss.
The Correct Answer is A
The nurse should report a positive rapid strep test of the oropharynx to the healthcare provider. Acute glomerulonephritis is often caused by a recent streptococcal infection, and a positive rapid strep test would confirm this as the underlying cause
A blood pressure of 88/50 mmHg is within the normal range for a child and would not need to be reported.
A maculopapular rash over the trunk of the body is not typically associated with acute glomerulonephritis and would not need to be reported.
Weight loss may occur with acute glomerulonephritis due to decreased appetite, but it is not an urgent finding that needs to be reported immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.
Touching the tonsillar pillars to stimulate the gag reflex or asking the child to speak would not provide information about the presence of bleeding.
Assessing for teeth clenching or grinding is not related to this particular observation.
Correct Answer is C
Explanation
The startle reflex, also known as the Moro reflex, is a normal reflex in infants that is present at birth and usually disappears by 3-4 months of age. The reflex is elicited by a sudden loud noise or change in position, and the infant will extend their arms and legs, then bring them back in towards their body.
If a 6-month-old infant is still demonstrating the startle reflex, it may indicate a developmental delay or neurological issue and requires further evaluation by the nurse or healthcare provider.
The other responses are all normal developmental milestones for a 6-month-old infant. By 6 months of age, most infants will have doubled their birth weight, enjoy playing games like peek-a-boo, and have developed the ability to turn their head to locate sounds.
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