The healthcare provider is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning the infant's care?

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Respiratory rate of 76 breaths/minute. The highest priority assessment finding in a 2-hour-old infant born by cesarean delivery is their respiratory status. Infants, especially those born via cesarean section, are at risk for respiratory distress syndrome due to incomplete lung development. A respiratory rate of 76 breaths/minute could indicate respiratory distress, which requires immediate intervention to ensure adequate oxygenation. Option A, blood pressure of 76/42 mmHg, is not as critical in this immediate postnatal period as respiratory status. Infants typically have lower blood pressure values compared to adults. Faint heart murmur (option B) is common in newborns and not necessarily a cause for concern at this stage. Option D, blood glucose of 45 mg/dl, is also important but not as urgent as addressing potential respiratory distress in a newborn. In an educational context, understanding the priorities in assessing a newborn's health is crucial for healthcare providers working in maternity care. This question highlights the significance of recognizing and managing respiratory distress promptly in newborns, emphasizing the need for quick and accurate assessment to ensure the well-being of the infant.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Numbness and inability to move fingers. When a cast is applied and elevated above the level of the heart during the drying process, there is a risk of compartment syndrome developing. Compartment syndrome occurs when there is increased pressure within a muscle compartment, leading to decreased blood flow and potential nerve damage. Numbness and the inability to move fingers are indicative of nerve compression and impaired circulation, which are serious complications requiring immediate attention to prevent permanent damage. Option A) Itching sensation under the cast is a common sensation due to the drying process and is not typically a cause for immediate concern. Option B) Swelling of fingers with brisk capillary refill is a normal response to the elevation of the cast and should resolve once the cast is fully dried and the limb is lowered. Option D) Visible bruising above the cast may indicate minor trauma during the application of the cast but is not a critical finding that requires immediate reporting. Educationally, it is important for healthcare providers to understand the signs and symptoms of compartment syndrome to prevent complications such as tissue necrosis and permanent nerve damage. Prompt recognition and intervention are crucial in managing this condition effectively and ensuring optimal patient outcomes.

Correct Answer: D

Rationale: To calculate the amount of terbutaline to administer, first convert the dose to the same unit. 250 mcg = 0.25 mg. Next, set up a proportion: 20 mg is to 1000 mL as 0.25 mg is to X mL. Cross multiply and solve for X: 20 X = 0.25 1000. X = (0.25 1000) / 20 = 12.5 mL. Therefore, the nurse should administer 13 mL of the solution.

Correct Answer: B

Rationale: Chorea, or sudden aimless movements associated with rheumatic fever, is temporary in nature and will eventually disappear on its own. It is important for the nurse to reassure the parents that these movements are part of the condition and typically resolve over time without the need for permanent lifestyle changes or strict discipline. Providing accurate information and reassurance to the parents can help alleviate concerns and promote understanding of the condition's course.

Correct Answer: A

Rationale: In this scenario, the highest priority action for the nurse caring for a one-year-old child following surgical correction of hypospadias is to monitor urinary output (Option A). This is because hypospadias repair surgery can lead to complications such as urinary retention, infection, or obstruction, which can impact the child's recovery and overall health. Monitoring urinary output is crucial in assessing renal function, fluid status, and the effectiveness of the surgical intervention. Changes in urinary output can indicate dehydration, renal complications, or issues with the surgical site. Early detection of these problems through monitoring urinary output allows for prompt intervention and prevents potential complications. The other options are not the highest priority in this situation. Auscultating bowel sounds (Option B) is important for assessing gastrointestinal function but is not as critical as monitoring urinary output in this postoperative period. Observing the appearance of stool (Option C) and recording the percent of diet consumed (Option D) are also important aspects of care but are not as immediate and essential as monitoring urinary output in this specific context. In an educational context, understanding the rationale behind prioritizing nursing actions based on the patient's condition and the potential complications of a surgical procedure is crucial for providing safe and effective care. Developing critical thinking skills to prioritize care based on the patient's needs and the clinical situation is a fundamental aspect of nursing practice in any specialty, including maternity care.