A nurse is assessing a toddler who has acute nephrotic syndrome. Which of the following findings should the nurse report to the provider?
Facial edema
Irritability
Poor appetite
Yellow nasal discharge
The Correct Answer is D
Rationale:
A. Facial edema is a common finding in nephrotic syndrome due to hypoalbuminemia and fluid retention.
B. Irritability can occur due to discomfort or malaise associated with the condition but is not immediately concerning.
C. Poor appetite is a common symptom in children with nephrotic syndrome and is expected.
D. Yellow nasal discharge may indicate an infection, which is a concern in children with nephrotic syndrome because they are at increased risk for infections due to their condition and the potential use of immunosuppressive therapies.
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Correct Answer is C
Explanation
Rationale:
A. Loosening restrictive clothing is important for ensuring the child’s comfort and preventing injury, but it is not the immediate priority.
B. Placing a pillow under the child’s head can help prevent head injury during a seizure, but positioning the child is more urgent to prevent aspiration.
C. Positioning the child side-lying is the priority because it helps maintain an open airway and reduces the risk of aspiration of vomit during the seizure. Protecting the airway is the most critical intervention in this scenario.
D. Clearing the area of hazards is important to prevent injury during the seizure, but it is secondary to ensuring the child's airway is protected.
Correct Answer is A
Explanation
Rationale:
A. Recording an upper extremity blood pressure (in the arms) compared to a lower extremity blood pressure (in the legs) can help reveal coarctation of the aorta, as the condition often results in higher blood pressure in the upper body and lower pressure in the lower body.
B. Assessing for femoral pulses is important but may not reveal coarctation of the aorta unless there is significant obstruction.
C. Excessive crying is not a specific indicator of coarctation of the aorta.
D. While a cardiac murmur can be associated with various heart conditions, it is not the most definitive assessment for coarctation of the aorta.