A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature ºF, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take?

Correct Answer: A

Rationale: The neonate is likely experiencing hypothermia with an axillary temperature below the normal range for a newborn. The best immediate action is to prevent further heat loss by wrapping the neonate warmly to maintain body temperature. Placing the neonate in an open crib will allow for better monitoring without the heat source of the radiant warmer. It is important to continue monitoring the neonate's temperature closely to ensure it returns to the normal range.

Correct Answer: B

Rationale: Minimal-change nephrotic syndrome is a kidney disorder characterized by the presence of proteinuria, which is the excessive loss of protein in the urine. This leads to low levels of protein in the blood, causing edema (swelling) due to fluid accumulation in the tissues. In minimal-change nephrotic syndrome, hypertension (high blood pressure) is not a typical finding. Instead, patients often present with normal blood pressure levels. Additionally, hematuria (presence of blood in the urine) is not a common symptom of this disorder. Therefore, the key signs and symptoms characteristic of minimal-change nephrotic syndrome are edema, proteinuria, and the absence of hypertension.

Correct Answer: C

Rationale: In a child with Cushing's syndrome, excessive levels of cortisol are present in the body. Cortisol can lead to hypertension (high blood pressure) and tachycardia (elevated heart rate). Therefore, closely monitoring vital signs for signs of hypertension and tachycardia is essential for early detection and management of these potential complications. Prompt identification and treatment of these cardiovascular issues can help prevent further complications and ensure the child's well-being.

Correct Answer: C

Rationale: Hemophilia is a condition where the blood fails to clot properly. Applying cold to the area can cause vasoconstriction (narrowing of blood vessels) which may slow down the blood flow and exacerbate the bleeding in individuals with hemophilia. Therefore, instructing Mr. and Mrs. Smith to avoid applying cold to the area of injury is crucial in order to prevent further complications.

Correct Answer: B

Rationale: The correct answer is B: Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy. In tetralogy of Fallot, these defects are present: 1. Ventricular septal defect: This is a hole in the wall that separates the two lower chambers of the heart, allowing mixing of oxygenated and deoxygenated blood. 2. Overriding aorta: The aorta is positioned directly over the ventricular septal defect, receiving blood from both ventricles. 3. Pulmonic stenosis (PS): Narrowing of the pulmonary valve or artery, leading to decreased blood flow to the lungs. 4. Right ventricular hypertrophy: The right ventricle becomes enlarged due to the increased workload of pumping blood through the narrowed pulmonary valve. Option A is incorrect as it describes transposition of the great arteries, not tetralogy of Fallot. Option C lists defects associated with other heart conditions like coarctation of aorta and aortic valve stenosis. Option D describes a different heart defect known as tricuspid atresia. Understanding these specific defects in tetralogy of Fallot is crucial for nurses caring for pediatric patients with congenital heart conditions. Recognizing these abnormalities helps in providing appropriate nursing care, monitoring for complications, and educating families on managing their child's condition effectively.