In fetal period, all are true EXCEPT

Correct Answer: D

Rationale: Face recognition typically occurs earlier than 26 weeks.

Correct Answer: C

Rationale: Decreased cardiac output is a serious concern in clients with congestive heart failure. By assessing the apical heart rate before administering digitalis, the nurse can monitor the client's cardiac status and prevent possible complications such as digitalis toxicity. Digitalis is a medication commonly used to improve cardiac output in clients with heart failure, but it can also cause harm if given inappropriately, especially if the client's heart rate is already low. Monitoring the client's apical heart rate before giving digitalis helps ensure that the medication is safely administered and that the client's cardiac status is closely monitored. This intervention is crucial in the care of clients with congestive heart failure to optimize patient safety and outcomes.

Correct Answer: A

Rationale: The highest priority nursing diagnosis in this scenario is Deficient fluid volume related to osmotic diuresis. The client's serum glucose level of 618mg/dl indicates severe hyperglycemia, which is likely causing osmotic diuresis leading to fluid volume deficit. The client's hot, dry skin, along with a heart rate of 116 beats/min, and blood pressure of 108/70mmHg are symptoms of dehydration due to fluid loss. If left untreated, deficient fluid volume can lead to serious complications such as hypovolemic shock. Therefore, addressing the fluid volume deficit is essential to stabilize the client's condition before other nursing diagnoses are addressed.

Correct Answer: A

Rationale: Before a client with impaired physical mobility gets up, the nurse should ensure that the appropriate assistive device is available and properly set up for the client to use. Using parallel bars or a walker provides support and stability, helping the client maintain balance and prevent falls while standing and walking. This would be the most suitable action to take before assisting the client in getting up to ensure their safety and mobility. Applying incontinence pads, an abdominal binder, or using a footboard are not directly related to the immediate need of assisting the client with impaired physical mobility in getting up.

Correct Answer: D

Rationale: Children with acute lymphocytic leukemia commonly present with a combination of symptoms which can include fatigability, persistent fever of unknown cause, and a tendency to bruise easily. Fatigue is a common complaint in children with leukemia due to anemia caused by decreased production of healthy red blood cells. Persistent fevers can be a sign of infection, anemia, or other complications related to leukemia. Additionally, children with leukemia may have a low platelet count, leading to easy bruising or bleeding tendencies. Therefore, all of the characteristics mentioned in the options are correct for a child with acute lymphocytic leukemia.

Correct Answer: B

Rationale: In chronic renal disease, the kidneys are not functioning properly, leading to an accumulation of phosphorus in the body. High levels of phosphorus can be harmful and contribute to bone and mineral disorders. Calcium carbonate is often given with meals to bind phosphorus in the gut and prevent its absorption. By binding with phosphorus, calcium carbonate helps lower the levels of phosphorus in the blood, thereby managing complications associated with chronic renal disease, such as renal osteodystrophy. It is an essential part of the treatment plan for patients with chronic kidney disease to help maintain appropriate phosphorus balance in the body and prevent further complications.

Correct Answer: D

Rationale: The most likely cause of her chief complaint this morning is a frequent complication of the hypophysectomy. A hypophysectomy is the surgical removal of the pituitary gland. One common complication following a hypophysectomy is diabetes insipidus, characterized by polyuria (excessive urination) and polydipsia (excessive thirst). This occurs because the removal of the pituitary gland can disrupt the regulation of antidiuretic hormone (ADH), which plays a key role in maintaining water balance in the body. Therefore, it is the most likely cause of the patient's chief complaint of polyuria this morning.

Correct Answer: A

Rationale: When performing a newborn assessment, it is important to measure the vital signs in the sequence of pulse, respirations, and temperature. This sequence is recommended because measuring the pulse first provides immediate information on the baby's cardiovascular status, followed by respirations to assess respiratory function, and ending with temperature which can be influenced by the other vital signs. This comprehensive approach helps ensure all vital signs are assessed accurately and in a logical order.

Correct Answer: A

Rationale: Younger age is a significant risk factor for extraneural metastasis in pediatric brain tumors.