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NurseDive Free Nursing Practice Question
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?
A. Pain
Pain. Pain is the hallmark symptom of a sickle cell crisis due to the vaso-occlusion of sickled red blood cells blocking blood flow and causing ischemia in various tissues and organs.
B. High fever
High fever. While fever can occur if there is an associated infection, it is not a primary feature of sickle cell crisis.
C. Bradycardia
Bradycardia. Sickle cell crisis can cause tachycardia due to pain and stress, but not bradycardia.
D. Constipation
Constipation. This is not a typical symptom associated with a sickle cell crisis.
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Full Explanation
A. Pain. Pain is the hallmark symptom of a sickle cell crisis due to the vaso-occlusion of sickled red blood cells blocking blood flow and causing ischemia in various tissues and organs.
B. High fever. While fever can occur if there is an associated infection, it is not a primary feature of sickle cell crisis.
C. Bradycardia. Sickle cell crisis can cause tachycardia due to pain and stress, but not bradycardia.
D. Constipation. This is not a typical symptom associated with a sickle cell crisis.
Similar Questions
A nurse is assessing a postmature infant. Which of the following findings would the nurse expect? (Select All that Apply.)
A. Vernix in the folds and creases
Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails
Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo
Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin
Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet
Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex
Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.
Full Explanation
A. Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.
Which newborn assessment finding would require the nurse to report to the health care provider?
A. The newborn who has cyanotic hands and feet.
The newborn who has cyanotic hands and feetCyanosis, a bluish or purplish discoloration of the skin, in the hands and feet of a newborn can indicate a breathing problem or poor circulation. This requires prompt evaluation by a healthcare provider.
B. The newborns whose head turns toward the cheek being stroked
The newborn whose head turns toward the cheek being stroked. This describes the rooting reflex, which is normal.
C. The newborn whose toes curl when the lateral heel is stroked
The newborn whose toes curl when the lateral heel is stroked. This describes the Babinski reflex, which is also normal for infants.
D. The newborn who extends the arms when hearing a loud noise
The newborn who extends the arms when hearing a loud noise. This describes the Moro reflex, which is normal and should not require reporting.
Full Explanation
A. The newborn who has cyanotic hands and feetCyanosis, a bluish or purplish discoloration of the skin, in the hands and feet of a newborn can indicate a breathing problem or poor circulation. This requires prompt evaluation by a healthcare provider.
B. The newborn whose head turns toward the cheek being stroked. This describes the rooting reflex, which is normal.
C. The newborn whose toes curl when the lateral heel is stroked. This describes the Babinski reflex, which is also normal for infants.
D. The newborn who extends the arms when hearing a loud noise. This describes the Moro reflex, which is normal and should not require reporting.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
A. Encourage the client to empty her bladder.
Encourage the client to empty her bladder. This might help if the fundus were not midline, but since it is firm and midline, it’s not necessary.
B. Notify the client's provider.
Notify the client's provider. Immediate notification is not required for these findings as they are within the expected range postpartum.
C. Increase the frequency of fundal massage.
Increase the frequency of fundal massage. Frequent fundal massage is not necessary since the fundus is already firm.
D. Document the findings and continue to monitor the client.
Document the findings and continue to monitor the client. A firm fundus with moderate bleeding and small clots can be normal in the immediate postpartum period. The nurse should document these findings and continue to monitor.
Full Explanation
A. Encourage the client to empty her bladder. This might help if the fundus were not midline, but since it is firm and midline, it’s not necessary.
B. Notify the client's provider. Immediate notification is not required for these findings as they are within the expected range postpartum.
C. Increase the frequency of fundal massage. Frequent fundal massage is not necessary since the fundus is already firm.
D. Document the findings and continue to monitor the client. A firm fundus with moderate bleeding and small clots can be normal in the immediate postpartum period. The nurse should document these findings and continue to monitor.