The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

Correct Answer: D

Rationale: In a postpartum client with a perineal hematoma, assessing heart rate and blood pressure is crucial as it can help determine the client's circulatory status. A perineal hematoma has the potential to cause significant blood loss leading to hypovolemia. Monitoring vital signs like heart rate and blood pressure can provide immediate information on the client's hemodynamic stability and guide further interventions if needed.

Correct Answer: C

Rationale: In this scenario, the correct intervention for the nurse to implement is to assess bilateral lung sounds (Option C). This is crucial because a 6-year-old with heart failure who has gained 2 pounds in the last 24 hours may be experiencing fluid overload, leading to pulmonary congestion and potentially exacerbating the heart failure. Assessing bilateral lung sounds allows the nurse to determine if there are any signs of pulmonary edema or congestion, which are common complications of heart failure. Early detection of these issues through lung auscultation can prompt timely interventions to prevent respiratory distress and further deterioration of the child's condition. The other options are not as pertinent in this situation: - Option A, graphing the daily weight for the past week, while important for monitoring trends in weight gain or loss, does not address the immediate concern of potential respiratory distress. - Option B, decreasing the IV flow rate, could be considered if there were signs of fluid overload, but assessing lung sounds would provide more direct information about the child's respiratory status. - Option D, restricting intake of oral fluids, may be necessary in some cases of fluid overload, but assessing lung sounds would provide more immediate information about the child's respiratory status and guide further interventions. In an educational context, this question highlights the importance of clinical assessment skills in pediatric nursing, especially in managing children with complex conditions like heart failure. Nurses must be able to recognize subtle signs and symptoms of complications early to provide timely and appropriate care to pediatric patients.

Correct Answer: B

Rationale: The correct answer is B) Change to latex-free gloves when handling the infant. This is the most important action for the nurse to take because the child is showing signs of an allergic reaction, likely due to a latex allergy. Given that the child has myelomeningocele, which is a neural tube defect, they may have a higher risk of developing allergies. Using latex-free gloves will help prevent further exposure to latex and reduce the risk of exacerbating the allergic symptoms. Option A) Auscultate the lungs for respiratory pneumonia is incorrect because the symptoms described are indicative of an allergic reaction, not respiratory pneumonia. Option C) Draw blood to analyze for streptococcal infection is incorrect because the symptoms are not suggestive of a streptococcal infection but rather an allergic reaction. Option D) Apply zinc oxide to the perineum with each diaper change is incorrect because it addresses diaper rash, which is not the primary concern in this scenario. In an educational context, it is important for healthcare providers to be aware of common allergies, such as latex, especially when caring for vulnerable populations like infants with myelomeningocele. Understanding the signs and symptoms of allergic reactions and knowing how to manage them is crucial in providing safe and effective care.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A: "Lower legs become progressively weaker, causing a waddling, unsteady gait." This characteristic of Duchenne muscular dystrophy (DMD) is crucial for the nurse to focus on during the initial teaching because it is a hallmark symptom of the disease. Understanding the progressive weakness in the lower extremities helps the nurse educate the family about mobility challenges the child may face, the need for assistive devices, and the importance of physical therapy to maintain function as long as possible. Option B, "Growth and development have been abnormal since birth," is incorrect because while DMD can impact growth and development due to muscle weakness, it is not the primary characteristic to focus on initially. Option C, "Muscular strength can be regained with physical exercise and therapy," is incorrect as DMD is a degenerative condition with progressive muscle weakness that cannot be reversed through exercise. Option D, "Respiratory dysfunction and aspiration are prime concerns at this stage of the disease," is incorrect as respiratory complications typically occur in later stages of DMD, not initially. Educationally, understanding the key clinical manifestations of DMD is essential for nurses caring for children with this condition. By focusing on the characteristic of progressive lower extremity weakness, nurses can provide targeted education and support to families to improve the child's quality of life and promote optimal function for as long as possible.

Correct Answer: B

Rationale: In this scenario, the correct nursing intervention is to "remove restraints one at a time to provide range of motion exercises" (Option B). This is the appropriate action because it promotes the child's comfort and prevents joint stiffness. By removing one restraint at a time, the nurse can assess the child's response, provide necessary care, and ensure proper circulation and skin integrity. Option A is incorrect because waiting for the healthcare provider's advice may delay necessary care and hinder the child's recovery. Option C is incorrect as it does not address the need for range of motion exercises or the potential risks associated with prolonged use of restraints. Option D is also incorrect as it does not prioritize providing range of motion exercises and may lead to skin breakdown if the restraints are left off for too long. Educationally, understanding the rationale behind the correct intervention is crucial for nurses caring for pediatric patients post-cleft lip repair. It is essential to prioritize the child's comfort, mobility, and overall well-being while considering the implications of restraint use. Nurses should be knowledgeable about appropriate interventions to promote optimal outcomes for their pediatric patients.