A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?
"I am concerned about my child's future participation in team sports."
"My child doesn't like to sit still for nebulizer treatments."
"My child has only a small amount of mucus after percussion therapy."
"I think that my child has been running a fever over the last couple of days."
The Correct Answer is C
Rationale:
A. Concerns about participation in team sports are important, but they do not directly warrant a request for a high-frequency chest compression vest.
B. Discomfort with nebulizer treatments suggests the need for alternate therapies but does not specifically indicate a need for the vest.
C. A statement regarding a small amount of mucus after percussion therapy suggests that traditional methods of airway clearance may not be effective enough, indicating a need for a high-frequency chest compression vest to help mobilize mucus.
D. A fever may indicate an infection or exacerbation but does not directly relate to the need for a high-frequency chest compression vest.
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Correct Answer is B
Explanation
Rationale:
A. While assessing pain level is important for comfort management, it is not the highest priority in the immediate postpartum period.
B. The amount of vaginal bleeding is critical to assess during the fourth stage of labor to identify potential postpartum hemorrhage, especially with oxytocin administration.
C. Although urinary output is important to monitor for bladder distension, it does not take precedence over bleeding assessment.
D. Fundal height assessment is necessary to ensure the uterus is contracting effectively, but again, it is secondary to monitoring for bleeding.
Correct Answer is A
Explanation
Rationale:
A. Irritability when being held may indicate increased intracranial pressure or complications related to the VP shunt placement and should be reported to the provider.
B. A heart rate of 122/min is within the normal range for an infant and does not require reporting.
C. Hypoactive bowel sounds may occur postoperatively, especially if the infant has not been fed or has been under anesthesia, and is not an immediate concern.
D. A urine specific gravity of 1.018 is within normal limits for infants and does not indicate a need for reporting.