When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?

Correct Answer: C

Rationale: The highest nursing priority when performing nursing care for a neonate after birth is giving the vitamin K injection. Vitamin K is essential for blood clotting, and neonates are born with low levels of this vitamin, putting them at risk for bleeding disorders. Administering the vitamin K injection helps prevent serious bleeding complications such as Vitamin K Deficiency Bleeding (VKDB). It is crucial to give this injection as soon as possible after birth to ensure the neonate receives adequate protection. Covering the neonate's head with a cap may help maintain body temperature but is not as critical as administering the vitamin K injection. Obtaining a dextrostix or giving the initial bath are important aspects of newborn care but do not take precedence over the administration of vitamin K.

Correct Answer: D

Rationale: Secondary vesicoureteral reflux is a condition where urine flows backward from the bladder into the ureters and possibly towards the kidneys due to an underlying cause. In the majority of cases, it results from an infection in the urinary tract, particularly in the bladder. The infection leads to inflammation and weakening of the valves that normally prevent urine from refluxing back towards the kidneys. This condition is more common in children but can also occur in adults. Treating the underlying infection is essential to managing secondary vesicoureteral reflux and preventing complications such as kidney damage.

Correct Answer: C

Rationale: Nurse Galina should recognize an open anterior fontanel as a normal finding in a 2-year-old child. The anterior fontanel is a soft spot on a baby's skull where the skull bones have not yet fused together. It usually closes by the time a child is 18 to 24 months old. The open fontanel at 2 years of age is within the normal range of closure, and it is not a cause for concern in this case. No need to notify the doctor, look for other signs of abuse, or ask about a family history of Tay-Sachs disease based on this finding.

Correct Answer: D

Rationale: In children diagnosed with sickle cell disease (SCD), tissue damage results from local tissue damage with ischemia and necrosis due to obstructed circulation. Sickle cell disease is a genetic disorder characterized by abnormal hemoglobin that causes red blood cells to assume a sickle shape. These sickle-shaped cells can adhere to blood vessel walls, leading to vaso-occlusion and impaired blood flow. This obstruction results in tissue ischemia and eventual necrosis, causing significant pain and organ damage. The chronic vaso-occlusive events in SCD are responsible for the development of acute and chronic complications seen in affected individuals, such as painful crises, stroke, and organ damage.

Correct Answer: D

Rationale: Kawasaki disease is an inflammatory condition that primarily affects medium-sized blood vessels, including the coronary arteries. If not promptly and effectively treated, about 25% of untreated cases can lead to the development of coronary artery aneurysms. These aneurysms can increase the risk of serious complications such as myocardial infarction and sudden death. Therefore, it is crucial to closely monitor and manage the cardiovascular complications in patients with Kawasaki disease, particularly the risk of aneurysm formation.