The nurse performs an assessment of a child with pertussis (whooping cough). Which finding would the nurse identify as indicative of a potential complication?
A urinary output of 30 mL/hr
A white blood cell (WBC) count of 10.000 mm3 (10×109/L)
Decreased breath sounds in the lung bases
A weight gain
The Correct Answer is C
A. A urinary output of 30 mL/hr
Explanation: While decreased urinary output may indicate dehydration, it is not a specific finding related to pertussis. Dehydration can occur due to inadequate fluid intake or loss through vomiting or sweating.
B. A white blood cell (WBC) count of 10,000 mm3 (10×10^9/L)
Explanation: An elevated white blood cell count is a common finding in infections, including pertussis. It reflects the body's immune response to the infection. A WBC count of 10,000 mm3 is within the normal range, and while it indicates an inflammatory response, it does not specifically point to a complication.
C. Decreased breath sounds in the lung bases
Explanation:
Pertussis is a respiratory infection caused by the bacterium Bordetella pertussis. Complications can arise, including pneumonia. Decreased breath sounds in the lung bases may suggest the presence of pneumonia, which is a serious complication of pertussis. Pneumonia can lead to respiratory distress and requires prompt medical attention.
D. A weight gain
Explanation: Weight gain is not typically associated with pertussis. In fact, respiratory distress and difficulty feeding during coughing paroxysms can lead to weight loss in infants with pertussis. Weight gain may be indicative of other unrelated factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Newborns are abdominal breathers."
Explanation: While it is true that newborns primarily use their diaphragms for breathing (abdominal breathing), this statement does not specifically address why the respiratory rate should be counted for a full minute.
B. "Activity will increase the respiratory rate."
Explanation: This statement acknowledges that activity can influence the respiratory rate but does not specifically address the need to count for a full minute to capture the irregular patterns.
C. "Newborns do not expand their lungs fully with each respiration."
Explanation: This statement highlights a characteristic of newborn respiratory physiology but does not specifically explain the importance of counting the respiratory rate for a full minute.
D. "The rate and rhythm of breath are irregular in newborns."
Explanation:
Newborns often have irregular breathing patterns, and counting the respiratory rate for a full minute helps capture the variations in rate and rhythm accurately. Newborns may experience periods of rapid breathing followed by periods of slower breathing, and their respiratory patterns can be influenced by sleep-wake cycles, feeding, and other factors. Counting for a full minute provides a more comprehensive and representative assessment of the newborn's respiratory status.
Correct Answer is A
Explanation
A. "Has the child had any difficulty swallowing food?"
Explanation:
One potential long-term effect of cleft palate repair is difficulty with swallowing or feeding. Cleft palate repair aims to improve the child's ability to eat and speak, but some children may continue to face challenges with swallowing or have a history of difficulty feeding.
B. "Does the child play with an imaginary friend?"
Explanation: Imaginary play is not specifically related to the long-term effects of cleft palate repair. This question does not provide information about the physical outcomes of the surgical repair.
C. "Does the child respond when called by name?"
Explanation: Responsiveness to being called by name is a general developmental question but does not specifically address the long-term effects of cleft palate repair.
D. "Was the child recently treated for pneumonia?"
Explanation: While respiratory issues can be associated with cleft palate, this question focuses on a recent event rather than the long-term effects. Asking about difficulty swallowing or feeding may provide more information about ongoing concerns related to the cleft palate repair.
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