The nurse is aware that a common physiologic adaptation of children with tetralogy of Fallot is:

Correct Answer: A

Rationale: Clubbing of fingers is a common physiologic adaptation seen in children with tetralogy of Fallot. Clubbing is the result of chronic hypoxia and decreased oxygen levels in the blood. In children with tetralogy of Fallot, there is a structural defect in the heart that leads to mixing of oxygenated and deoxygenated blood in the heart and decreased oxygenation of the blood circulating to the body. This chronic hypoxia can cause clubbing of the fingers, where the tips of the fingers appear enlarged and the nails are rounded. Therefore, clubbing of fingers is a key sign to monitor in children with tetralogy of Fallot.

Correct Answer: B

Rationale: In a patient with diabetes insipidus (DI) who is on fluid restrictions, monitoring urine output is crucial to assess the effectiveness of the treatment regimen. DI is a condition characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH). By monitoring urine output, the nurse can determine if the restrictions are achieving the goal of decreasing urine volume and preventing dehydration. Changes in urine output can also indicate the need for adjustments in the treatment plan. Monitoring oral intake, appearance of mucous membranes, and pulse and temperature are important aspects of pediatric care but are not as directly related to managing fluid restrictions in a patient with DI.

Correct Answer: D

Rationale: Rheumatic fever is an inflammatory disease that can develop as a complication of inadequately treated streptococcal infections, especially streptococcal throat infections caused by group A streptococcus bacteria. The bacteria trigger an abnormal immune response in susceptible individuals, leading to the development of rheumatic fever. The other choices are not accurate. Glomerulonephritis is a separate condition associated with certain types of streptococcal infections but not with rheumatic fever. Symptoms of rheumatic fever can persist even after the fever has subsided, and it is important for children with rheumatic fever to follow proper treatment and rest guidelines as advised by healthcare providers. It is crucial for individuals with rheumatic fever to avoid activities that could strain the heart until the condition has been properly managed.

Correct Answer: C

Rationale: Ortolani's sign is a physical exam maneuver used to detect congenital hip dislocation in infants. When performing Ortolani's sign, the nurse gently abducts the hips and feels the femoral head slipping back into the acetabulum. This is considered a positive finding and suggests the presence of hip dysplasia. Barlow's test, on the other hand, involves gently adducting the hip to feel for instability and potential dislocation. Jackson's sign is a maneuver for detecting hip dislocation by observing leg length discrepancy. Trendelenburg's sign is a test for hip abductor weakness. Hematuria is the presence of blood in urine and is not related to hip exams or signs.

Correct Answer: A

Rationale: The anterior fontanel, also known as the bregma, is the larger of the two fontanels located on the baby's skull. It is diamond-shaped, with the sutures meeting in the center to create a space that is soft and slightly depressed. While it is diamond-shaped when looking at the intersection of the sutures, when palpated or touched by a nurse, it often feels more circular due to the softness of the fontanel. It is important for nurses to monitor the fontanels for normal closure and development in newborns.