When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?
Review transcutaneous bilirubin levels with a bilirubinometer.
Observe and palpate newborn's breast tissue for enlargement.
Assess for signs of fluid retention and bilateral pedal edema.
Explain to the mother that the finding is due to increased androgen.
The Correct Answer is D
A) Incorrect- Reviewing transcutaneous bilirubin levels is unrelated to the presence of an enlarged clitoris. Bilirubin levels are typically assessed to monitor jaundice in newborns.
B) Incorrect- Observing and palpating breast tissue for enlargement is not relevant to the condition of salt-wasting congenital adrenal hyperplasia. Breast tissue enlargement would not be associated with this hormonal disorder.
C) Incorrect- Assessing for signs of fluid retention and bilateral pedal edema is important for monitoring for other conditions, but it is not relevant to the enlarged clitoris seen in this specific scenario.
D) Correct- Salt-wasting congenital adrenal hyperplasia is a genetic disorder that results in a deficiency of certain enzymes required for cortisol and aldosterone production. This deficiency leads to an overproduction of androgens, which can cause virilization of female external genitalia. The enlarged clitoris is a result of increased androgen levels. Explaining this finding to the mother provides her with accurate information about the condition and its effects on the infant's anatomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The presence of purulent drainage at the wound indicates a potential infection, and monitoring the client's WBC count is an important laboratory value to assess for signs of infection. An elevated WBC count, specifically an increase in the neutrophil count (neutrophilia), can indicate an active infection and provide important information for the healthcare provider when evaluating the wound.
While hematocrit, platelet count, and creatinine level are essential laboratory values to assess the client's overall condition, they may not provide specific information regarding the presence of infection or purulent drainage at the wound site.
Correct Answer is D
Explanation
The correct answer is choice D: Begin chest compressions at 100/minute.
Choice A rationale:
Observing for swelling at the fracture site is not immediately relevant in this emergency situation. The priority is to address the lack of pulse and respiration.
Choice B rationale:
Analyzing the cardiac rhythm in another lead is unnecessary when the patient has no pulse and is not breathing. Immediate life-saving measures are required.
Choice C rationale:
Obtaining a 12-lead electrocardiogram is not the priority in this scenario. The patient needs immediate resuscitation efforts.
Choice D rationale:
Beginning chest compressions at 100/minute is the correct intervention. The absence of a carotid pulse and spontaneous respirations indicates cardiac arrest, and chest compressions are essential to maintain circulation and oxygenation until further help arrives.
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