Fluid & Electrolytes

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period?

Bradycardia with no change in respirations In the postpartum period a slow pulse rate may result from a combination of factors, including decreased cardiovascular workload, emotional relief and satisfaction, and rest after labor and birth; respirations generally are unchanged. The temperature may rise slightly.

Two hours after a 1-year-old child with acute laryngitis is admitted to the hospital, the nurse observes increases in the child's respiratory and cardiac rates, increased restlessness, and substernal and intercostal retractions. What action should the nurse take immediately?

Calling the healthcare provider to report the child's respiratory status A tracheostomy may be necessary to maintain an open airway; therefore the healthcare provider needs to be notified immediately. The child's change in status is not indicative of increased secretions. Suctioning could precipitate laryngospasm and should be avoided in this case. Increased oxygen therapy will be ineffective with a severe spasm of the airway. Striking the child on the back is ineffective against laryngeal spasm.

A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical examination and administration of immunizations. Which clinical finding should prompt the nurse to perform further assessment?

Circumoral Cyanosis Circumoral cyanosis is not a specific characteristic of Down syndrome. It is a clinical finding associated with congenital heart disease, which infants with Down syndrome may have as a concurrent problem. A flat occiput and a broad nose with a depressed bridge (saddle nose) are features of children with Down syndrome. Small, misshapen, low-set ears are also a clinical manifestation of Down syndrome. Children with Down syndrome often keep their mouths open, with their tongues protruding; the surface of the tongue is often wrinkled.

A client is admitted via the emergency department with the tentative diagnosis of diverticulitis. Which test commonly is prescribed to assess for this problem?

Computed tomography scan (CT) A CT scan with contrast is the test of choice for diverticulitis because it effectively reflects the involved colon. An endoscopy assesses the upper, not lower, gastrointestinal tract. Colonoscopy is contraindicated because of the possibility of perforation and peritonitis. Barium enema is contraindicated because of the possibility of perforation and peritonitis.

External fetal uterine monitoring is started for a client in active labor. A nurse identifies fetal heart rate decelerations in a uniform wave shape that reflects the shape of the contraction. What is the nurse's next action?

Continuing to monitor the client for the return of the fetal heart rate to baseline when each contraction ends The reading noted by the nurse represents early decelerations that occur with head compression during a contraction, with the fetal heart rate (FHR) returning to baseline at the end of the contraction. Head compression and cord compression are both common occurrences during a contraction; intervention is unnecessary if the FHR returns to baseline at the end of the contraction. The dorsal recumbent position will increase pressure on the vena cava and is contraindicated.

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. What test result should the nurse anticipate for this infant?

Decreased blood pH In addition to increased PCO2, hypoxia from inadequate oxygen/carbon dioxide exchange leads to anaerobic metabolism with an accumulation of acid by-products; both lower blood pH. PO2 is decreased because inadequate lung surface area is available for diffusion of gases. Acidosis, not alkalosis, is present; bicarbonate will be normal or increased in the body's attempt to compensate. PCO2 increases because inadequate lung surface area is available for the diffusion of gases.

The nurse is caring for a client who is having a precipitous labor. For which complication should the nurse make a focused nursing assessment when a rapid descent of the fetus is experienced?

Fetal Head Trauma If there is bony or soft tissue resistance to the descent and birth, trauma to the fetal head may occur. Microcephaly is not associated with a birth event. A fractured coccyx is not associated with precipitous labor or birth. Although the placenta may be retained, this is not a specific complication of a precipitous birth.

A jogger sustains multiple fractures of the femur after being hit by a motor vehicle. A nurse responds to the scene of the accident to assist with care. The nurse recalls that, for this type of fracture, immediate life-threatening systemic complications can be minimized by doing what?

Handling and transporting the client gently Gentle intervention reduces pain and shock and inhibits the release of bone marrow into the system, which can cause a fat embolism. Elevation of the affected limb will not prevent a fat embolus; it may limit edema and pain, which are local effects. Deep breathing and coughing will not prevent a fat embolus; they are not a priority at the scene of an accident. Maintaining the client's limb in the position in which it is found is necessary during transport to the hospital.

A nurse in the prenatal clinic reviews second-trimester physiological changes in the hematological system before explaining them to a client. What is one of the changes the nurse should identify?

Increased Blood Volume Blood volume increases by approximately 50% during pregnancy; peak blood volume occurs between 30 and 34 weeks' gestation. Hematocrit decreases as a result of hemodilution. White blood cell count remains stable during the prenatal period. Sedimentation rate increases because of a decrease in plasma proteins.

The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test?

Instruct her to void immediately before the test The client is instructed to void immediately before the test is done to help prevent injury to the bladder as the needle is introduced into the amniotic sac . The supine position with a hip roll under the right hip is the preferred position for this procedure. Telling the client to assume the high Fowler position before the test will cause the bladder to fill, making it vulnerable to injury as the needle is inserted into the amniotic sac. Encouraging the client to drink three glasses of water before the test is advised if the amniocentesis is being performed early during pregnancy. There is no reason to withhold food or fluid, because the test does not involve the gastrointestinal tract.

A 3-month-old infant with chronic constipation has a tentative diagnosis of Hirschsprung disease. What definitive diagnostic test does the nurse expect to prepare the infant for?

Rectal Biopsy During a rectal biopsy a specimen is obtained and examined for the absence of ganglion cells. Hirschsprung disease is also known as congenital aganglionic megacolon. A sweat test is performed to determine the presence of cystic fibrosis. The Guthrie test is performed on a neonate to determine the presence of inborn errors of metabolism. The blood glucose level is unrelated to the diagnosis of Hirschsprung disease.

A client at 36 weeks gestation is admitted to the high-risk unit with the diagnosis of severe preeclampsia, and antiseizure therapy is instituted. A fetal monitor and an electronic blood pressure machine are applied. Which complication of severe preeclampsia requires diligent monitoring of the blood pressure?

Stroke The likelihood of a stroke increases with a rising blood pressure reading. The degree of hypertension is not associated with hemorrhage. The course of labor is not affected by blood pressure changes except in the presence of abruptio placentae. Fluctuations in blood pressure do not affect the status of clotting factors.

A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction?

Troponin T (cTnT) Troponin T has an extraordinarily high specificity for myocardial cell injury. Cardiac troponins elevate sooner and remain elevated longer than many of the other enzymes that reflect myocardial injury. ALT is found predominantly in the liver; it is found in lesser quantities in the kidneys, heart, and skeletal muscles, and is primarily used to diagnose and monitor liver, not heart, disease. AST, also known as serum glutamic-oxaloacetic transaminase (SGOT), is elevated 8 hours after a myocardial infarction. Total LDH levels elevate 24 to 48 hours after a myocardial infarction.

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which manifestations of excessive levels of ADH should the nurse assess the client? Select all that apply.

Weight gain Hyponatremia Excessive levels of ADH cause inappropriate free water retention; for every liter of fluid retained, the client will gain approximately 2.2 lb. Free water retention results in a hypoosmolar state with dilutional hyponatremia. Oliguria, not polyuria, occurs as ADH acts on nephrons to cause water to be reabsorbed from the glomerular filtrate. Because of water reabsorption, blood volume may increase, causing hypertension, not hypotension. This increases, not decreases, as a result of increased urine concentration.

A gavage feeding is prescribed for an infant. How does the nurse determine the length of tube needed to reach the stomach?

A measurement is made from earlobe to nose and then to the epigastric area. Before inserting the gastric tube, the nurse measures the anatomical pathway that the tube will travel, which is from the nose to the earlobe (corresponding to the nasopharynx) to the epigastric area of the abdomen (the lower end of the stomach). The tube is then marked and inserted until the mark is reached. Advancing the tube without measuring for the potential length of the tube to reach the stomach is unsafe. Without premeasuring, the tube may be advanced too far or not far enough. Inserting the tube to the point where gastric contents are aspirated may not place the tube well into the stomach, which can increase the risk of aspiration. Measuring from mouth to umbilicus and then adding half that distance will yield a distance that is too long.

A 15-month-old child with the diagnosis of hydrocephalus is to undergo computed tomography (CT). What action should the nurse include when preparing the toddler for the CT scan?

Administering the prescribed sedative A 15-month-old toddler will have difficulty complying with directions to remain still and may be extremely frightened by the equipment, so sedatives are usually prescribed. Shaving the head is not necessary; the head must remain still but need not be shaved. Starting the prescribed infusion is not necessary unless a contrast medium is being used. The child is too young to understand even a simple explanation of the procedure.

A client has just been told that she has cervical erosion. The nurse would expect to help explain that early treatment of the erosion can help prevent what?

Cancer of the cervix Erosion of the cervix frequently occurs at the columnosquamous junction, the most common site for carcinoma of the cervix. Treatment of cervical erosions does not prevent pelvic inflammatory disease; early onset of sexual intercourse (before 16 years of age), multiple sexual partners, and history of human papillomavirus (HPV) infection are risk factors for cancer of the cervix rather than consequences of precervical cancer. Metrorrhagia, abnormal bleeding from the uterus, may be present as erosion develops into carcinoma; however, spotting may be the earliest sign and will be eliminated when the cancer is treated. The goal of treatment of the erosion is to prevent cancer.

A nurse is caring for a 9-year-old child with juvenile idiopathic arthritis (JIA). What is most important for the nurse to attempt to prevent?

Contracture Deformities Severe joint pain and swelling cause the child with JIA to immobilize the affected parts for prolonged periods, resulting in joint deformities. The disease process is inflammatory but usually noninfectious. Bleeding into the joints (hemarthrosis) is not part of the disease process. JIA is not related to the mental development of the child, but it may contribute to a physical developmental delay.

A woman is being seen in the prenatal clinic at 36 weeks' gestation. The nurse is reviewing signs and symptoms that should be reported to health care provider with the mother. Which signs and symptoms require further evaluation by the health care provider? Select all that apply.

Decreased urine output Blurred vision with spots Severe headache Decreased urine output, blurred vision, and severe headache may occur with pregnancy-associated hypertension. Urinary frequency occurs in the first trimester and again in the third trimester as the uterus settles back into the pelvis. The weight of the uterus may delay emptying of the stomach and make heartburn a more frequent problem. Shortness of breath would be expected after the client climbs a flight of stairs.

A client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. What should the nurse consider when formulating a response?

Less thyroid tissue is available to supply thyroid hormone after surgery. After a thyroidectomy, thyroxine output usually is inadequate to maintain an appropriate metabolic rate. Hypothyroidism is decreased thyroid functioning, not a slowing of functions of the entire body. With hypothyroidism, the level of TSH from the pituitary usually is increased. Thyroid tissue remaining after surgery does not atrophy.

The nurse is rendering preoperative care to a child with a Wilms tumor. What is the most important aspect of this care?

Monitoring blood pressure Blood pressure monitoring is important because the tumor is of renal origin and the renin-angiotensin mechanism may be involved. Palpating the liver should be avoided; it puts pressure on the involved area, increasing the risk rupture of the tumor and seeding of cancer cells. There are no data to indicate that the child has a urinary tract infection. Lying in the prone position puts pressure on the involved area, increasing the risk rupture of the tumor and seeding of cancer cells.

The nurse is planning care for a middle-aged woman who has been admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. What should the nurse tell the client to expect in the immediate postoperative period?

Presence of a urinary catheter After surgery the urethral orifice may be distorted and edematous; a urine retention catheter keeps the bladder empty, limiting pressure on the operative site. A pessary placed in the vagina is used for a displaced uterus; after an anteroposterior repair (colporrhaphy), vaginal packing is used to support the surgical repair. A rectal tube is used for abdominal distention caused by flatulence; it is rarely necessary. A cleansing douche may be prescribed before, not after, surgery.

The nurse is developing a care plan for a client with postpartum psychosis. Which priority intervention should the nurse implement?

Referring the client to a psychiatric healthcare provider as prescribed Assessment and management of postpartum psychosis are beyond the scope of a maternity nurse. A mother who experiences this condition must be referred to a specialist for comprehensive therapy. Women with signs of postpartum psychosis need immediate medical attention to prevent suicide or infanticide. In light of this psychiatric emergency condition it would not be appropriate to plan bonding time for the client and infant, teach her about normal newborn care, or allow expression of her feelings.

A nurse is caring for a client who had radical neck surgery. For which complication associated with this surgery should the nurse assess this client?

Rupture of the carotid artery Because of the proximity of the carotid artery to the surgical area and the possibility that age or the disease process has weakened the carotid artery, the client should be monitored for signs of hemorrhage related to carotid rupture. Pulmonary edema and cardiogenic shock are related to cardiac decompensation, which are not expected complications of radical neck surgery. With a radical neck dissection the trapezius muscle, not chest muscles, may atrophy.

The nurse is providing immediate postoperative care to a client who had a thyroidectomy. The nurse should monitor the client for which clinical manifestation?

Signs of respiratory obstruction The first and most important observation should be for signs of respiratory obstruction. Tracheal compression can occur because of edema in the surgical area. Tracheal compression is exhibited by decreased inspiratory/expiratory pressure, decreased ventilation, dyspnea, shortness of breath, tachypnea, tachycardia, nasal flaring, use of accessory muscles to breathe, cyanosis, reduced oxygen saturation, and altered arterial blood gases. Although urinary retention is a concern after anesthesia, it is not life threatening. Signs of restlessness may be a result of the anesthesia; however, if it is because of a lack of oxygenation, assessing for respiratory obstruction is a more direct and objective assessment associated with this surgery. The blood pressure is not significantly affected by this type of surgery unless thyroid storm occurs; when assessing for thyroid storm all the vital signs will increase.

A toddler who has undergone cleft palate repair is now able to tolerate fluids. What should the nurse use to offer the toddler fluids?

Small Cup Feeding with a small cup is best because liquids can be given slowly, without stress on the suture line; also, a cup is age appropriate for a toddler. Sucking on a nipple may exert pressure on the suture line. Feeding with a syringe increases the chances of damage to the suture line and may result in aspiration. Feeding with a spoon increases the risks of damage to the suture line.

A client is admitted to the birthing unit because fluid is leaking from her vagina. She is unsure whether her "bag of water" has broken. What should the nurse do to help determine whether the fluid is amniotic fluid?

Test the fluid with nitrazine paper Amniotic fluid is slightly alkaline, and urine is acidic; when moistened with amniotic fluid, Nitrazine will turn dark blue, indicating an alkaline substance. Inspecting the fluid is a subjective assessment and may be inaccurate. Protein is not a discriminating factor, because it may be present in urine and amniotic fluid, especially in the urine, if the client shows signs of preeclampsia. The fluid need not be sent to the laboratory; it can be tested immediately for alkalinity with Nitrazine paper.

A nurse is preparing to take the vital signs of a 4-year-old child who was brought to the well-child clinic. What criterion should the nurse use when selecting the appropriate size of blood pressure cuff?

The width is approximately 40% of the circumference of the upper arm. Research has demonstrated that a cuff with a bladder width that is 40% of the arm circumference will usually have a bladder length that is 80% to 100% of the upper arm circumference. Using a cuff of this size for this child will yield the most accurate blood pressure reading. Children vary in weight and height; although a cuff may be appropriate for pediatric patients or preschoolers of average weight and height, it may not be suitable for all such children. The cuff bladder length should cover 80% to 100% of the circumference of the upper arm.

A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is which type?

Type A or O negative Both A and O negative blood are compatible with the client's blood. A negative is the same as the client's blood type and preferred; in an emergency, type O negative blood also may be given. Although type O blood may be used, it will have to be Rh negative; Rh positive blood is incompatible with the client's blood and will cause hemolysis. Type AB positive blood is incompatible with the client's blood and will cause hemolysis. Type A negative blood is compatible with the client's blood, but type AB negative is incompatible and will cause hemolysis.

Which complication should the nurse assess in a client who had a bilateral herniorrhaphy?

Urinary retention Because of pain and the proximity of the operative site to the lower urinary tract, voiding problems are common. Hydrocele is not a complication of herniorrhaphy. The abdomen was not entered, and interference with peristalsis should not occur. Thrombophlebitis should not be a complication of herniorrhaphy because early ambulation is encouraged.