HESI - Legal/Pathophysiology

Which condition contraindicates oxytocin induction? - Chorioamnionitis - Postterm pregnancy - Active genital herpes infection - Hypertension associated with pregnancy

- Active genital herpes infection Oxytocin is not administered when a woman has an active genital herpes infection. In this case, the baby would be delivered by means of cesarean section to prevent it from being infected during birth. Chorioamnionitis, hypertension associated with pregnancy, and postterm pregnancy are all indications for the use of oxytocin induction.

Which autoantigens are responsible for the development of Crohn disease? - Crypt epithelial cells - Thyroid cell surface - Basement membranes of the lungs - Basement membranes of the glomeruli

- Crypt epithelial cells Crypt epithelial cells are considered the autoantigens responsible for Crohn disease. Thyroid cell surfaces are autoantigens responsible for Hashimoto thyroiditis. The pulmonary and glomerular basement membranes act as autoantigens responsible for Goodpasture syndrome.

Urine specific gravity range

1.005 to 1.030

The nurse applies an ice pack to a client's leg for a total of 20 minutes. Which physiological effect would occur because of applying cold therapy?

Local anesthesia.

Which intestinal obstruction is a concern for hospitalized preterm infants?

Necrotizing Enterocolitis - Common in preterm babies due to the immaturity of the child's digestive system. - Inflammation of the intestine leading to bacterial invasion causing cellular damage and cellular death and necrosis of the colon and intestine

What is the best description of an AV graft?

Synthetic tubing tunneled beneath the skin connecting an artery and a vein.

While assessing the stool sample of an infant, the nurse finds that the infant has passed golden-colored stool. Which would the nurse interpret from this finding?

The infant is breastfeeding

Abnormal sign from a complication experienced from shoulder dystocia

Unilateral absence of moro reflex. - Behavior of a fractured clavicle

Which manifestation of hypertrophic pyloric stenosis in an infant would the nurse expect when palpating the abdomen? - A distended colon - Marked tenderness around the umbilicus - An olive-sized mass in the right upper quadrant - Rhythmic peristaltic waves in the lower abdomen

- An olive-sized mass in the right upper quadrant The olive-like mass is caused by the thickened muscle (hypertrophy) of the pyloric sphincter. The obstruction is above the intestinal area; the colon is not involved. There is no significant tenderness in the abdomen. There is little or no peristalsis in the intestines.

The nurse is reviewing the medical records of several clients. Which client has a condition that is an autoimmune disorder? - Addison disease - Cushing syndrome - Hashimoto disease - Sheehan syndrome

- Hashimoto disease Hashimoto disease is an autoimmune disorder, wherein the immune system attacks the thyroid gland. Addison disease is caused by adrenal insufficiency. Cushing syndrome is caused by increased body levels of cortisol. Sheehan syndrome is hemorrhage-associated hypopituitarism after delivery of a child.

Assessment for AV graft

- Palpate for thrill - Auscultate for bruit - Pulse distal to the graft

Which is the primary developmental milestone to be accomplished between 12 and 15 months of age? - Walk erect - Climb stairs - Use a spoon - Say simple words

- Walk erect Walking is the primary developmental milestone for this age group; 1-year-olds are capable of the balance and agility required for walking. A child learns to climb stairs around 15 to 18 months of age. The ability to use a spoon is not developed until 18 months of age. Speaking is not the priority at this age.

Which assessment finding would the nurse recognize as the Ortolani sign? - Unilateral droop of the hip - Broadening of the perineum - Apparent shortening of one leg - Audible click on hip manipulation

- Audible click on hip manipulation

The parents of a preschooler with a congenital heart defect asks the nurse why their child squats after exertion. Which rationale would the nurse provide the parents? - Decreases the number of muscle aches - Improves walking capacity and hip mobility - Reduces how hard the heart must work - Helps more blood return to the heart

- Reduces how hard the heart must work When the child squats, blood pools in the lower extremities because of hip and knee flexion, which causes less blood to return to the heart and reduces how hard the heart must work (cardiac workload). For this young child, squatting after exertion does not reduce muscle aches, it is unrelated to walking capacity and hip mobility, and it decreases (not increases) blood return to the heart.

Which position would the nurse select for an infant with hydrocephalus? - On either side and supine - Supine and Trendelenburg - Prone, with the legs elevated about 30 degrees - Supine, with the head elevated about 45 degrees

- Supine, with the head elevated about 45 degrees The head should be elevated, allowing gravity to minimize intracranial pressure. The Trendelenburg position is contraindicated because it can increase intracranial pressure. The infant should be positioned on the back or side to allow routine changes in head position; prone positioning is unsafe for infants and increases the risk of sudden infant death syndrome.

Mononucleosis manifestations

- Swollen lymph nodes - Ear pain - Fever

A child with type 2 diabetes is scheduled for abdominal surgery. Which factors are most important for the nurse to consider during the postoperative period? Select all that apply. - Infection will likely occur at the surgical site. - Ketoacidosis frequently occurs later in the postoperative period. - The blood glucose level will increase because of the stress of surgery. - Urine test results are the most useful gauge of diabetic control after surgery. - Diabetic control is usually maintained with insulin after surgery.

- The blood glucose level will increase because of the stress of surgery. - Diabetic control is usually maintained with insulin after surgery. The stress of surgery causes the release of epinephrine and glucocorticoids, which increase the blood glucose level. Most individuals with type 2 diabetes who control their diabetes through diet and exercise require insulin during the recovery period. Although the child with diabetes is at risk for infection, surgical aseptic technique should prevent infection. Ketoacidosis is associated with type 1, not type 2, diabetes. Urine test results are affected by many variables and are not reliable indicators of the blood glucose level.

A client reports diminished sensations of pain, touch, and temperature on the skin. The nurse touches the skin and finds it cool. Which skin changes would the nurse relate to the client's findings? - Degenerated elastic fibers - Decreased blood flow to the skin - Increased melanocytes in basal layer - Decreased activity of the apocrine glands

- Decreased blood flow to the skin Decreased blood flow to the skin may cause diminished sensations of pain, touch, and temperature. The skin may also feel cold. Degeneration of elastic fibers may cause increased wrinkling and sagging of the breasts. Increased melanocytes in the basal layers may cause solar lentigines. Decreased activity of the apocrine glands may be related to uneven skin color and dry skin.

Which risk factors relate to the use of hemodialysis?

- Hemorrhage - Orthostatic hypotension

Which organism causes Hansen's disease? - Clostridium tetani - Haemophilus pertussis - Mycobacterium leprae - Legionella pneumophila

- Mycobacterium leprae Mycobacterium leprae causes Hansen's disease (leprosy). Clostridium tetani causes tetanus (lockjaw). Haemophilus pertussis causes pertussis (whooping cough), and Legionella pneumophila causes pneumonia (Legionnaires' disease).

Which priority nursing action would the nurse implement for an infant recently admitted with a diagnosis of diarrhea caused by a Salmonella infection? - Monitoring oral fluid intake - Establishing a play schedule - Obtaining a recent food history - Establishing a skin care routine

- Establishing a skin care routine Enzymes in the stool may irritate the skin; maintaining skin integrity is the priority. Fluid intake is important to monitor for dehydration, though some infants may receive IV fluids. Establishing a play schedule is not the priority of care. Physiologic problems, such as altered skin integrity, should be addressed first. Although obtaining a food history is important, it is not the priority.

Manifestations of high blood sugar during pregnancy

- Increased thirst and urination - Headache and flushed, dry skin

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition is indicated with this result? - Cystic fibrosis - Phenylketonuria - Down syndrome - Neural tube defect

- Neural tube defect Increased levels of alpha-fetoprotein in pregnant women have been found to reflect open neural tube defects such as spina bifida and anencephaly. Cystic fibrosis is a genetic defect that is not associated with the AFP level. A Guthrie test soon after ingestion of formula can determine whether an infant has phenylketonuria. Down syndrome is a chromosomal defect that is associated with a low AFP level.

A postpartum client expresses concern that her problems associated with endometriosis will return now that her pregnancy is over. Which is an appropriate response by the nurse? - "Pregnancy usually cures the problem." - "Endometriosis usually causes early menopause." - "You may need a hysterectomy if the problems recur." - "Breast-feeding will delay the return of the endometriosis."

- "Breast-feeding will delay the return of the endometriosis." Lactation delays ovarian function during the postpartum period; therefore, lactation will delay the return of endometriosis. Pregnancy temporarily suppresses ovarian function; the aberrant endometrial tissue is still present. Endometriosis may lead to sterility; it does not cause menopause. Conservative medical therapy will be used first; hysterectomy is a last resort.

The nurse is teaching a young adolescent with type 2 diabetes about nutritional needs. Which statement demonstrates that the adolescent understands what was taught? - "I can have low-fat, low-cal candy bars." - "Regular soft drinks are better than diet ones." - "It's okay for me to eat one slice of pizza at a party." - "My fasting blood sugar should be no higher than 150 mg/dL (8.3 mmol/L)."

- "It's okay for me to eat one slice of pizza at a party." Pizza contains complex carbohydrates and protein; even a child with type 2 diabetes may include a slice in the diet on special occasions. Although candy bars can be low in fat and calories, they may still have a high simple sugar content, which is contraindicated. Diet, not regular, soft drinks are preferred for an individual with type 2 diabetes; regular soft drinks are high in simple sugars. The euglycemic fasting blood glucose should be 70 to 105 mg/dL (3.9-5.8 mmol/L).

Which parent education would the nurse provide the mother of a 5-month-old boy who is concerned that her son no longer turns his head toward her breast when she touches his cheek? - "Is he able to sit unsupported?" - "Usually this reflex disappears around 4 months." - "Do his toes still flare out when you stroke the sole of his foot?" - "Please have him evaluated; he may have a feeding problem."

- "Usually this reflex disappears around 4 months." The mother is describing the rooting reflex; when touched on the cheek, the infant reflexively turns the head to that side. The rooting reflex is expected to disappear by 4 months of age. An infant can sit without support at 8 months; this is not expected of a 5-month-old infant. Stroking the sole of the foot elicits the Babinski reflex, which disappears between 8 and 12 months of age. The disappearance of the rooting reflex at 5 months of age does not require further intervention.

Which assessment finding in a newborn is suggestive of cystic fibrosis? - Rapid heart rate - Excessive crying - Sternal retractions - Abdominal distention

- Abdominal distention Meconium ileus is an indication that a newborn may have cystic fibrosis. The small intestine is blocked with thick, tenacious, mucilaginous meconium, usually near the ileocecal valve. This causes intestinal obstruction with abdominal distention, vomiting, and fluid and electrolyte imbalance. Rapid heart rate is not a sign of cystic fibrosis in the newborn. Excessive crying does not have special significance in cystic fibrosis. Sternal retractions are not a sign of cystic fibrosis in the newborn.

Which parent education would the nurse include about the cause of most cases of otitis media? - A virus - Bacteria - A fungus - Rickettsia

- Bacteria Otitis media, one of the most prevalent illnesses in toddlers, is caused by a bacterial infection. The causative agent is not a fungus, virus, or rickettsial organism.

Which description is common to zosteriform-type lesions? - Wide distribution - Diffuse distribution - Bilateral distribution - Band-like distribution

- Band-like distribution Band-like distribution of lesions would be termed as zosteriform-type lesions. Diffuse-type lesions are described as the wide distribution of the lesions. Generalized-type lesions are identified by the diffused distribution of the lesions. Symmetric-type lesions are the bilateral distribution of the lesions.

Which is the priority of care for a child who was recently diagnosed with celiac disease? - Preventing celiac crisis and resulting problems - Minimizing complications of respiratory involvement - Teaching the parents to establish a diet that promotes optimal growth - Helping the parents and child adjust to the long-term dietary restrictions

- Helping the parents and child adjust to the long-term dietary restrictions Adherence to dietary restrictions can prevent future complications and celiac crisis. Celiac crisis usually develops as a result of nonadherence to the diet, so adherence to the diet, rather than preventing celiac crisis, is the primary objective

Which teeth would the nurse expect to erupt first in a typically developing 6-month-old infant? - Incisors - Canines - Upper molars - Lower molars

- Incisors The bottom incisors are the first teeth to erupt, between 6 and 8 months of age. The canine teeth appear around 18 months. The first molars, both upper and lower, appear around 20 months.

A client with hyperemesis gravidarum is to be maintained at home with rehydration infusion therapy. Which is the prioritynursing activity for the home health nurse? - Determining fetal well-being - Monitoring for signs of infection - Monitoring the client for signs of electrolyte imbalance - Teaching about changes in nutritional needs during pregnancy

- Monitoring the client for signs of electrolyte imbalance Rehydration fluids contain only saline and dextrose; if the client continues to vomit, she will lose electrolytes. Monitoring the fetus is not the priority at this time. Although there is a danger of infection when an intravenous line is in place, monitoring for it is not the priority. Teaching about nutritional needs is not a priority while the client is vomiting.

Which assessment would the nurse perform while caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS)? - Quality of the cry - Signs of dehydration - Coughing up of feedings - Characteristics of the stool

- Signs of dehydration Hypertrophic pyloric stenosis is a thickening or swelling of the pylorus — the muscle between the stomach and the intestines — that causes severe and forceful vomiting in the first few months of life. Hypertrophic pyloric stenosis causes partial and then complete obstruction. Nonprojectile vomiting progresses to projectile vomiting, which rapidly leads to dehydration. The infant's cry is not affected by HPS; pain, except for the pain of hunger, does not appear to be associated with this condition. An infant with a tracheoesophageal fistula, not HPS, is expected to cough up feedings. The characteristics of the stool are not relevant in the assessment of an infant with HPS.

Gestational diabetes pathophysiology consideration

- Testing at 28 weeks - Hormonal changes between the second and third trimester leads to increased maternal insulin resistance

Maximum amount of interdialytic (between dialysis treatments) weight gain.

1.5 kg

What is the purpose of a health care proxy or durable power of attorney for health care?

Designated a person of persons to make health care decisions on behalf of the client.

The nurse concludes that the parents of a newborn with Erb's palsy have an accurate understanding of the infant's prognosis. Which statement made by the parents confirms this conclusion? - "Surgery will correct the palsy." - "This is a progressive disorder with no cure." - "Recovery usually occurs in about 3 months." - "Physical therapy will be necessary for 1 year."

- "Recovery usually occurs in about 3 months." The arm nerves that are stretched in Erb's palsy, take about 3 months to recover from the trauma sustained during birth. Passive range-of-motion exercise and intermittent splinting performed by a trained family member will help facilitate recovery. Only in rare instances, when avulsion of the nerves results in permanent damage, is orthopedic or surgical intervention necessary. The paralysis is not progressive, and the prognosis is usually excellent. Physical therapy is necessary for about 3 months, not 1 year.

The nurse is assessing head growth in an 8-month-old infant. The nurse observes that the rate of the infant's growth has been 0.5 cm per month since the 6-month checkup. Which conclusion would the nurse convey to the parents regarding their child's development? - "The child needs to be screened." - "The child's head growth is normal." - "The child's posterior fontanel is not fused." - "There may be some developmental issues."

- "The child's head growth is normal." After the sixth month, the infant's head grows at 0.5 cm every month. The nurse informs the parents that the head growth rate is normal for the child. There is no need for screening, because the child has not received any head injuries. There may be developmental issues if the head growth is not normal. The posterior fontanel is fused at 6 to 8 weeks of age, so this is not a plausible finding at the 8-month mark.

An infant has had a chest tube inserted after the open repair of a fractured sternum from a motor vehicle collision. Which parent education would the nurse provide to the infant's parents about the chest tube? - "The tube doesn't cause discomfort. It's been put in place for emergency use." - "The tube will be taken out once your baby is stable and oral feedings are started." - "The tube has been placed to drain the air that entered the chest cavity during surgery." - "The tube drains the air that accumulated in your baby's chest after the lung was punctured."

- "The tube has been placed to drain the air that entered the chest cavity during surgery." The chest was opened during surgery for sternal repair, allowing air to enter the pleural space; the air must be removed for the lungs to expand. Chest tubes are uncomfortable; also, saying it is in place for emergency use discounts the importance of the chest tube to the infant's respiratory status. The chest tube is unrelated to the infant's ability to ingest oral feedings. The data do not indicate the presence of a punctured lung.

A parent tells the nurse, "My 9-month-old doesn't have the same strong grasp as at birth, and my child is not startled by loud noises anymore." Which education would the nurse provide the parent to explain these changes in behavior? - "Let me check these responses before deciding how to proceed." - "When these responses fail, it may indicate a developmental delay." - "The baby needs more sensory stimulation to get these responses back." - "Those responses are replaced by voluntary activity around 5 months of age."

- "Those responses are replaced by voluntary activity around 5 months of age." Touching the palm of a newborn causes flexion of the fingers (grasp reflex); this response usually diminishes after 3 months of age. An unexpected loud noise causes the newborn to abduct the extremities and then flex the elbows (startle reflex); this response usually disappears by 4 months of age. Persistence of primitive reflexes is usually indicative of a developmental delay. It is not necessary to gather more data, because these changes are consistent with expected growth and development. The data do not support the conclusion that the child is developmentally delayed and saying so may cause needless concern. Sensory stimulation at this age is directed toward experiences to add new motor, language, and social skills.

Which childhood disease is best described as a viral disease that starts with malaise and a highly pruritic rash that begins on the abdomen and spreads to the face and proximal extremities and can result in grave complications? - Rubella - Rubeola - Chickenpox - Scarlet fever

- Chickenpox Varicella (chickenpox) begins with a slight fever, malaise, and anorexia. After 24 hours a highly pruritic rash begins with a macule and progresses to papules and then vesicles that break easily. The rash spreads in a centripetal manner from the trunk to the face and proximal extremities. Secondary bacterial complications (e.g., encephalitis, pneumonia, and hemorrhagic varicella) are potential complications. Rubella is a benign communicable childhood disease; complications are rare, but women of childbearing age should be vaccinated because rubella, if contracted in early pregnancy, can cause congenital anomalies in the newborn. Rubeola (measles) produces coldlike respiratory symptoms and, after 3 or 4 days, a dark-red macular or maculopapular skin rash. Scarlet fever is a bacterial infection that responds to antibiotic therapy and does not cause major complications.

Which clinical finding would prompt the nurse to perform further assessment of an infant with Down syndrome? - Flat occiput - Small, low-set ears - Circumoral cyanosis - Protruding furrowed tongue

- Circumoral cyanosis Circumoral cyanosis is not a specific characteristic of Down syndrome. It is a clinical finding associated with congenital heart disease, which may co-occur in a child with Down syndrome. 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.

Which postoperative nursing care would the nurse provide to a 3-week-old infant after surgery to repair a cleft lip? - Using a spoon to administer oral feedings - Cleansing the suture line to prevent infection - Offering a pacifier for sucking to prevent crying - Using wrist restraints to keep the infant's hands away from the face

- Cleansing the suture line to prevent infection Meticulous care of the suture line is necessary to prevent infection and to help ensure the best cosmetic outcome. Using a spoon is contraindicated, because it could disrupt the suture line; the infant may be fed with a device designed especially for this purpose. Offering a pacifier is contraindicated, because sucking will put tension on the suture line and may result in disruption of the sutures. Elbow restraints are used; this allows the infant to move the arms without bending the elbows and thus prevents the infant from touching the face.

Which intervention would the nurse provide a 3-month-old infant hospitalized with respiratory syncytial virus (RSV)? - Administering an antiviral agent - Clustering care to conserve energy - Administering a bronchodilator every four hours - Providing an antitussive agent whenever necessary

- Clustering care to conserve energy Often the infant will have a decreased pulmonary reserve, and the clustering of care is essential to provide for periods of rest. Antiviral therapy is controversial for this age group and is not given unless complications ensue. Bronchodilators are not routinely indicated for RSV. Antitussive agents are not used; nasal secretions are aspirated with the use of a bulb syringe whenever necessary.

A client is diagnosed with an eczematous eruption with well-defined and geometric margins on the scalp. Which condition would the nurse anticipate teaching the client about? - Medication eruption - Atopic dermatitis - Contact dermatitis - Nonspecific eczematous dermatitis

- Contact dermatitis The diagnostic feature of contact dermatitis is the presence of localized eczematous eruptions with well-defined and geometric margins. The diagnostic feature of medication eruption is the presence of bright-red erythematous macules and papules in large areas. In atopic dermatitis, the client has lichenification with scaling and excoriation, which causes extreme itching. In nonspecific eczematous dermatitis, lesions evolve from vesicles to weeping papules and plaques.

Which pathophysiological abnormality is present in cystic fibrosis? - Dysfunction of sweat glands - Inactivity of respiratory tract cilia - Dysfunction of mucus-secreting glands - Overproduction of endocrine gland activity

- Dysfunction of mucus-secreting glands Cystic fibrosis is a genetic disorder affecting all mucus-secreting (exocrine) glands. A sweat gland abnormality is not involved in cystic fibrosis; children with cystic fibrosis lose excessive amounts of sodium through perspiration caused by exocrine gland dysfunction. Cilia action may be influenced by the thickened secretions, but the cilia are not affected by cystic fibrosis. Exocrine, not endocrine, glands are involved in cystic fibrosis.

A client has had surgery for a ruptured fallopian tube from an ectopic pregnancy. Which information would be included in the postoperative teaching plan? - Effect on future pregnancies - How to prevent another tubal pregnancy - Need for Rho (D) immune globulin to prevent isoimmunization - Importance of not douching after intercourse, because this may dislodge a fertilized egg

- Effect on future pregnancies Removing a fallopian tube does not impair the ovaries' ability to release an egg, which may be fertilized in the remaining tube if it is undamaged. There is no known way to prevent future tubal pregnancies. There is no information to indicate that the client is Rh negative, requiring the administration of Rho (D) immune globulin. Liquid from a douche does not reach the fallopian tube or dislodge a fertilized egg; in addition, douching is no longer recommended at any time.

Which plan of care would the nurse provide for a newborn with hypospadias? - Preparing the infant for insertion of a cystostomy tube - Explaining to the parents the genetic basis for the defect - Keeping the infant's penis wrapped with petrolatum gauze - Giving the parents reasons why circumcision should not be performed

- Giving the parents reasons why circumcision should not be performed The parents need to know why circumcision should not be performed. The foreskin may be needed for repair and reconstruction of the penis. A cystostomy tube is not inserted, because there is no interference with voiding. Hypospadias is not a genetic disorder, although there appears to be some evidence that it is familial. The penis is generally wrapped in petrolatum gauze after, not before, surgical correction of hypospadias.

Six weeks after birth an infant is found to have developmental dysplasia of the hip. The nurse explains to the parents the benefits of early treatment. Which is the rationale for the immediate institution of corrective measures? - Mobility will be delayed if correction is postponed. - Traction is effective if it is used before toddlerhood. - Infants are easier to manage in spica casts than are toddlers. - Infants' cartilaginous hip joints promote molding of the acetabulum.

- Infants' cartilaginous hip joints promote molding of the acetabulum. The cartilaginous hip joints are the basis for the use of abduction devices (e.g., Pavlik harness) and spica casts when the infant is very young. Congenital hip dysplasia does not limit ambulation for the young child, although the gait will be affected. Traction is not used to correct developmental dysplasia of the hip. Although casted infants are easier to manage than casted toddlers, this is not the reason for early treatment.

Which hormones are involved in building and maintaining healthy bone tissue? Select all that apply. One, some, or all responses may be correct. - Insulin - Thyroxine - Glucocorticoids - Growth hormone - Parathyroid hormone

- Insulin - Glucocorticoids - Growth hormone Insulin works together with growth hormone to increase bone length, which helps build and maintain healthy bone tissue. Glucocorticoids regulate protein metabolism to reduce or intensify the organic matrix of bone. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion stimulates bones to promote osteoclastic activity and release calcium into the blood when serum calcium levels are lowered.

Which part of the kidney produces the hormone bradykinin? - Kidney tissues - Kidney parenchyma - Renin-producing granular cells - Juxtaglomerular cells of the arterioles

- Juxtaglomerular cells of the arterioles The juxtaglomerular cells of the arterioles produce the hormone bradykinin, which increases blood flow and vascular permeability. The kidney tissues produce prostaglandins that regulate internal blood flow by vasodilation or vasoconstriction. The kidney parenchyma produces erythropoietin that stimulates the bone marrow to make red blood cells. The renin-producing granular cells produce the renin hormone that raises blood pressure as a result of angiotensin and aldosterone secretion.

Which characteristics would the nurse expect infants with failure to thrive to exhibit? Select all that apply. One, some, or all responses may be correct. - Hyperactivity - Language deficit - Being overweight - Tendency to illness - Responsiveness to stimuli

- Language deficit - Tendency to illness Infants with undernutrition and failure to thrive often have developmental delays, including language, motor, social, and adaptive deficits. Infants with failure to thrive are usually frail and are at risk for physical and emotional illnesses. Infants with failure to thrive are usually quiet and lethargic,not hyperactive. Being overweight is not characteristic of infants with failure to thrive; infants are usually underweight (below the fifth percentile). Responsiveness to stimuli is limited or nonexistent with failure to thrive.

Which complications would the nurse recognize as associated with frequent episodes of otitis media in infants? Select all that apply. One, some, or all responses may be correct. - Mastoiditis - Heart failure - Hearing loss - Gastroenteritis - Bacterial meningitis

- Mastoiditis - Hearing loss - Bacterial meningitis Mastoiditis is an inflammation of the mastoid gland; it may occur as a complication of otitis media because of the mastoid gland's proximity to the ear. Hearing loss is a common complication of otitis media; the child should be assessed frequently for this problem. Infections of surrounding organs may occur; meningitis is a complication of otitis media. Heart failure and gastroenteritis are not complications of otitis media.

The nurse is obtaining a health history from a client with endometriosis. Which consequences can occur as a result of this disorder? Select all that apply. One, some, or all responses may be correct. - Menopause - Metrorrhagia - Impaired fertility - Bowel strictures - Voiding difficulties

- Metrorrhagia - Impaired fertility - Bowel strictures - Voiding difficulties Endometriosis is when cells similar to the lining of the uterus, or endometrium, grow outside of the uterus. Metrorrhagia is a possible complication; bleeding between periods is due to the bleeding of endometrial tissue outside the uterus. The excessive tissue in endometriosis may impinge on the colon and cause ribbonlike stools. The endometrial tissue may impinge on the bladder and ureters and cause voiding difficulties. Impaired fertility may result from adhesions around the uterus that pull the uterus into a fixed, retroverted position. Endometriosis does not cause menopause.

Which intestinal obstruction is a concern for hospitalized preterm infants? - Meconium ileus - Imperforate anus - Duodenal atresia - Necrotizing enterocolitis

- Necrotizing enterocolitis Necrotizing enterocolitis is an inflammatory disorder of the gastrointestinal mucosa related to several factors, including prematurity, hypoxemia, and high-solute feedings. Meconium ileus is an intestinal obstruction present at birth that is usually related to cystic fibrosis. Imperforate anus is the failure of fetal tissue to develop appropriately early in gestation; it is present at birth. Duodenal atresia is a genetic defect that occurs early in gestation; it, too, is present at birth.

The nurse is caring for a 3-month-old infant whose abdomen is distended and whose vomitus is bile stained. Which clinical manifestations support the suspicion of intestinal obstruction? Select all that apply. One, some, or all responses may be correct. - Weak pulse - Hypotonicity - High-pitched cry - Paroxysmal pain - Grunting respirations

- Paroxysmal pain - Grunting respirations Paroxysmal pain is related to the peristaltic action associated with intestinal obstruction. Abdominal distention pushes the diaphragm upward, causing respiratory distress characterized by grunting respirations. Weak pulse and hypotonicity are not directly correlated to intestinal obstruction. A high-pitched cry is typically related to neurologic conditions.

A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. Which is the priority nursing intervention? - Increasing physical activities - Performing postural drainage - Maintaining dietary restrictions - Administering prescribed pancreatic enzymes

- Performing postural drainage Postural drainage, including percussion and vibration, aids removal of respiratory secretions that provide a medium for further bacterial growth. Children with CF must cope with impaired gas exchange that results in intolerance to activity. Increasing activity at this time may be too taxing. There must be a balance between activity and rest within the child's limitations. There are no dietary restrictions. Children with CF should have a balanced nutritional intake that is high in calories. Although important, administration of prescribed pancreatic enzymes is not the priority.

Which intervention would the nurse implement for a 4-month-old infant with tetralogy of Fallot and heart failure? - Providing small, frequent feedings - Positioning the child flat on the back - Encouraging frequent nutritional fluids - Measuring the head circumference daily

- Providing small, frequent feedings Small, frequent feedings with adequate rest periods in between may improve the infant's intake at each feeding; infants with tetralogy of Fallot become extremely fatigued while feeding. Positioning the child with the head elevated, not flat on the back, facilitates respiration; an infant cardiac seat, similar to a car seat, helps maintain the child in the semi-Fowler position. As a means of reducing the cardiac workload, excessive fluids usually are not offered, and fluids may even be restricted. The head circumference is not an important assessment for infants with congenital heart disease; daily head measurements should be taken for infants with hydrocephaly.