the nurse is caring for a 5 year old child with reyes syndrome which goal of treatment most clearly relates to caring for this child
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Nursing Elites

HESI RN

Maternity HESI 2023 Quizlet

1. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child?

Correct answer: A

Rationale: Reducing cerebral edema and lowering intracranial pressure is the primary goal of treatment for Reye’s syndrome.

2. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?

Correct answer: A

Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.

3. A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?

Correct answer: C

Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective. Choices A, B, and D are incorrect because they do not directly reflect the expected outcome of epoetin alfa therapy. Increasing urinary output, changes in respiratory rate, and decreasing bilirubin levels are not primary indicators of the drug's effectiveness in this context.

4. During a non-stress test (NST) at 41-weeks gestation, the LPN/LVN notes that the client is not experiencing contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are present. What action should the nurse take?

Correct answer: D

Rationale: In this scenario, the nurse should ask the client if she has felt any fetal movement. This action is important as assessing for fetal movement can help determine if the absence of FHR accelerations is attributed to fetal sleep or decreased fetal activity. It is crucial to gather information directly from the client to aid in the assessment and decision-making process. This approach can provide valuable insights into the fetal well-being and guide further interventions if needed.

5. During a routine first-trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?

Correct answer: C

Rationale: The increased vaginal discharge described by the pregnant client, which is white, thin, and watery, is a common physiological change during pregnancy. It is typically normal and attributed to hormonal fluctuations. The nurse should reassure the client that this type of discharge is expected during pregnancy and does not typically indicate an issue requiring medical intervention or treatment.

Similar Questions

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Upon admission to the prenatal clinic, a 23-year-old woman informs the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. What is this client's expected date of delivery (EDD)?
During a woman's first prenatal visit, the nurse reviews her health care record, noting a history of chickenpox as a child and syphilis as a teenager. Which action is most important for the nurse to take?
The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child’s head appears large in relation to body size. Which action is most important for the nurse to take next?
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the LPN/LVN take?

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