A nurse is assessing a 7-year-old who has been diagnosed with acute pyelonephritis, what assessment finding requires immediate action by the nurse?
Blood pressure of 136/92 mg
Heart rate of 100 bpm
Decreased urine output
Tea-colored urine
The Correct Answer is A
Rationale:
A. Hypertension (blood pressure of 136/92 mm Hg) in a child with acute pyelonephritis can indicate a severe condition that may lead to renal damage or worsening kidney function. Immediate intervention is necessary to manage high blood pressure and prevent complications.
B. A heart rate of 100 bpm is within normal limits for a 7-year-old and does not require immediate action.
C. Decreased urine output is concerning and needs monitoring, but hypertension is the more urgent issue.
D. Tea-colored urine suggests hematuria or concentrated urine, which is important but not as immediately life-threatening as high blood pressure.
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Correct Answer is D
Explanation
Rationale:
A. Oral penicillin is not a primary treatment for nephrotic syndrome. Antibiotics may be used if there is an associated infection, but they are not central to the management of nephrotic syndrome itself.
B. Labetalol is a medication used for hypertension and would not be specifically indicated for nephrotic syndrome unless hypertension is present.
C. Aggressive intravenous fluid resuscitation is not typically used in nephrotic syndrome; instead, fluid management focuses on balancing fluid intake and output carefully.
D. Prednisone, a corticosteroid, is commonly used to reduce inflammation and proteinuria in nephrotic syndrome. It helps to manage the condition effectively by addressing the underlying inflammation.
Correct Answer is B
Explanation
Rationale:
A. Offering a pacifier is contraindicated after cleft lip and palate repair as it can disrupt the surgical site and interfere with healing.
B. Maintaining elbow restraints prevents the infant from touching or putting objects in their mouth, which could disrupt the surgical site and compromise healing.
C. The Trendelenburg position is not recommended as it can increase pressure on the surgical site and compromise breathing.
A
D. An ice collar may be used for pain relief in older children or adults but is not typically used in infants, and it may not be feasible in this population.