24 hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:

Correct Answer: A

Rationale: Hyperacute rejection occurs immediately after transplantation, within minutes to up to 24 hours. It is a rapid and severe rejection reaction that is usually irreversible. It occurs due to pre-existing antibodies against the donor organ. In hyperacute rejection, the transplanted kidney must be removed to prevent further complications and ensure the safety of the patient. Treatment with immunosuppressive medications like cyclosporine or corticosteroids is not effective in this situation. Bone marrow transplant is not indicated in the treatment of hyperacute rejection.

Correct Answer: A

Rationale: Caput succedaneum is the vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. It is often caused by pressure from the vaginal wall during labor. This condition does not involve the calvarial bone and typically resolves on its own within a few days after birth. Hydrocephalus refers to the abnormal accumulation of cerebrospinal fluid within the brain, which can result in an enlarged head circumference. Cephalhematoma is a collection of blood between the periosteum and the skull bone, usually occurring after birth trauma. Subdural hematoma is bleeding between the dura mater and the arachnoid mater surrounding the brain and is typically seen in traumatic head injuries.

Correct Answer: C

Rationale: The most appropriate intervention to decrease cardiac demands and minimize cardiac workload in children with heart disease is to schedule care to provide uninterrupted rest periods. By allowing the child to rest without interruptions, their heart will not have to work as hard, promoting better overall cardiac function. This intervention focuses on promoting rest and recovery, which is crucial for children with heart disease to maintain optimal cardiac health. Feeding the infant over long periods may not necessarily decrease cardiac demands, and allowing the infant to have her way to avoid conflict is not related to cardiac workload. Developing and implementing a consistent care plan is important but may not directly decrease cardiac demands as effectively as scheduling care for uninterrupted rest periods.

Correct Answer: D

Rationale: Neonatal diabetes is not commonly associated with prenatal cigarette smoke exposure.

Correct Answer: C

Rationale: When suctioning a patient, it is important to limit the suctioning time to avoid hypoxia and tissue trauma. The maximum recommended time for suctioning an adult patient is usually around 10-15 seconds. However, in some cases, such as when dealing with thick or excessive secretions, the maximum time can be extended up to 30 seconds. In this particular case, where James is likely experiencing respiratory distress due to his symptoms, it would be appropriate for Wilma to suction him for a maximum of 30 seconds to effectively clear his airways while minimizing the risk of complications.