Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

Correct Answer: D

Rationale: The correct answer is D: Reduction of edema. Albumin helps reduce edema by increasing oncotic pressure, drawing fluid back into the blood vessels. In nephrotic syndrome, there is an abnormal loss of protein in the urine, leading to decreased oncotic pressure and fluid shifting into the interstitial spaces, causing edema. Administering albumin helps restore the oncotic pressure, reducing edema, which is a desirable effect of the medication.

Correct Answer: D

Rationale: When a client is receiving oxytocin to augment labor, the most crucial assessment for the nurse to obtain each time the infusion rate is increased is monitoring the contraction pattern. Increasing the infusion rate of oxytocin can lead to stronger and more frequent contractions, which can have implications for both the mother and the baby. Monitoring the contraction pattern helps ensure the safe administration of oxytocin and allows for timely interventions if needed.

Correct Answer: B

Rationale: In this scenario, the priority action for the nurse is to notify the healthcare provider from the client's bedside. The clinical presentation of severe abdominal pain, bright red vaginal bleeding, rigid and tender abdomen, along with fetal bradycardia (FHR 90 bpm) and maternal tachycardia (120 bpm) indicates an urgent need for medical intervention. Notifying the healthcare provider promptly allows for immediate assessment and decision-making to address the critical condition and ensure timely and appropriate management for both the mother and fetus.

Correct Answer: A

Rationale: In caring for a 5-year-old child with Reye's syndrome, the primary goal of treatment is to reduce cerebral edema and lower intracranial pressure (Option A). Reye's syndrome is characterized by swelling in the brain and increased pressure inside the skull, which can lead to serious neurological consequences. By focusing on reducing cerebral edema and lowering intracranial pressure, the nurse aims to protect the brain from further damage and promote neurological recovery. Option B, avert hypotension and septic shock, is incorrect as these conditions are not typically associated with Reye's syndrome. Option C, prevent cardiac arrhythmias and heart failure, is also incorrect as cardiac complications are not the primary concern in Reye's syndrome. Option D, promote kidney perfusion and normal blood pressure, is not directly related to the pathophysiology and treatment goals of Reye's syndrome. In an educational context, it is crucial for nurses to understand the specific goals of treatment for different pediatric conditions like Reye's syndrome. By knowing the primary objectives of care, nurses can provide targeted and effective interventions to optimize patient outcomes and prevent complications.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take next is option C: Palpate the anterior fontanel for tension and bulging. This is the most important step because an increase in the frontal occipital circumference (FOC) and a large head in relation to body size could indicate hydrocephalus or increased intracranial pressure in the infant. Palpating the anterior fontanel can help the nurse assess for signs of tension and bulging, which are concerning indicators in this situation. Option A, measuring the infant's head-to-heel length, is not the most appropriate next step as it does not directly address the potential issue of increased FOC and head size in relation to body size. Option B, observing the infant for sunsetting eyes, is not the priority at this time as it is a symptom of increased intracranial pressure but does not provide immediate assessment of the situation. Option D, plotting the measurement on the infant's growth chart, can be done after palpating the fontanel to track growth but is not the most urgent action in this case. Educationally, this scenario highlights the importance of recognizing abnormal findings in infant assessments and the need for timely and appropriate actions to address potential health concerns. Understanding the significance of changes in head circumference and knowing how to assess for signs of increased intracranial pressure are critical skills for nurses caring for infants.