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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is choice D. Demonstrate to the PN how to position the client more effectively for the procedure.

Choice A rationale:

Arranging for unlicensed assistive personnel to assist the PN during the procedure does not address the incorrect positioning of the client. The priority is to ensure the client is positioned correctly for the sigmoidoscopy, which is typically on the left side with knees drawn toward the chest.

Choice B rationale:

Acknowledging that the PN has positioned the client safely and correctly is not appropriate because the flat prone position is incorrect for a sigmoidoscopy. The correct position is on the left side with knees drawn toward the chest.

Choice C rationale:

Assuming care of the client and assigning the PN to the care of a different client does not address the educational opportunity. It is important to demonstrate the correct positioning to the PN to ensure proper care in future procedures.

Choice D rationale:

Demonstrating to the PN how to position the client more effectively for the procedure is the correct action. This ensures the client is in the proper position for the sigmoidoscopy and provides an educational opportunity for the PN.

A. Current prescribed and over-the-counter medications. B. Next scheduled visit with healthcare provider. C. Methods currently used to treat constipation. D. Daily food and fluid intake. E. Level of physical activity and exercise.

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

Explanation

Certain medications can contribute to constipation as a side effect. Reviewing the client's medication list will help identify any potential medications that may be causing or exacerbating constipation.

Understanding the client's current approach to managing constipation, such as dietary changes, laxative use, or other remedies, will provide insight into their self-care practices and effectiveness of current interventions.

Diet plays a crucial role in bowel regularity. Assessing the client's dietary habits, including fiber intake and hydration, can help identify potential factors contributing to constipation.

Physical activity and exercise promote bowel regularity by stimulating intestinal motility. Evaluating the client's level of physical activity and exercise routine can provide information on their overall mobility and potential impact on bowel function.

The next scheduled visit with the healthcare provider may be important for the overall management of the client's health but may not be directly related to formulating a plan of care specifically for constipation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is D

Explanation

The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply.)

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

Explanation

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