The nurse analyzes the laboratory values of a pediatric client with leukemia who is receiving chemotherapy. The nurse notes the following lab values: platelets 19,500/mcl (nl. 140,000-400,000/mcL), hemoglobin 11 g/dL (nl. 12-16 g/dL), white blood cell count 9,800/mcl (nl. 5,000-10,000/mcL). Based on these findings, which intervention should the nurse prioritize in the plan of care?
Monitoring closely for signs of infection.
Transfusing packed red blood cells.
Administering intravenous immunoglobulins.
Initiating bleeding precautions.
The Correct Answer is D
Rationale:
A. Monitoring for infection is important, but the white blood cell count is within normal limits, so it is not the immediate priority.
B. Although the hemoglobin is slightly low, it is not critically low, so transfusion of packed red blood cells is not immediately necessary.
C. Intravenous immunoglobulins are not indicated based on the current lab values.
D. The platelet count is critically low, placing the client at high risk for bleeding. Initiating bleeding precautions is the priority to prevent hemorrhage.
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Correct Answer is A
Explanation
Rationale:
A. Developmental dysplasia of the hip (DDH) often presents with a limited range of motion in the affected hip, particularly in abduction.
B. Asymmetry of the gluteal skinfolds, not symmetry, is a typical finding in DDH. This asymmetry is due to the improper alignment of the hip joint.
C. A positive Barlow test, where the hip can be dislocated by adduction and posterior pressure, is indicative of DDH. A negative Barlow test would suggest the absence of DDH.
D. A pale and cool leg is not a common finding in DDH. This would be more indicative of a circulatory problem, not hip dysplasia.
Correct Answer is D
Explanation
Rationale:
A. Tea-colored urine is more typical of glomerulonephritis rather than nephrotic syndrome.
B. A recent streptococcus infection is commonly associated with post-streptococcal glomerulonephritis, not nephrotic syndrome.
C. Polyuria is not a common feature of nephrotic syndrome; rather, oliguria (decreased urine output) may occur.
D. Periorbital edema is a hallmark sign of nephrotic syndrome, resulting from significant protein loss in the urine, leading to hypoalbuminemia and fluid retention.