A mother calls her pediatrician's office concerned about her 7-month-old son. She gave him peanuts for the second time for lunch and he has vomited three times is coughing and looks flushed. What is the priority of the nurse?
Give Benadryl PO and monitor for the next 2 hours
Recommend symptomatic treatment for the cough
Tell the mother to call 911
Administer CPR to the child
The Correct Answer is C
The symptoms described, including vomiting, coughing, and looking flushed, are concerning for a potentially severe allergic reaction, which can be life-threatening. This could be indicative of anaphylaxis, a severe allergic reaction that requires immediate medical attention.
Administering CPR (Option D) is not appropriate at this point unless the child becomes unresponsive and stops breathing, which would be a very late sign of anaphylaxis. In such a situation, CPR would be necessary, but the primary focus should be on calling 911 and obtaining immediate medical assistance.
Option A, giving Benadryl, can be part of the treatment for an allergic reaction, but it should not be the first or only action taken in a severe allergic reaction. Immediate medical evaluation and potential administration of epinephrine are more critical.
Option B, recommending symptomatic treatment for the cough, is not appropriate in this situation. The priority is recognizing the potential severity of the allergic reaction and seeking immediate emergency care.
Therefore, the nurse should advise the mother to call 911 to ensure that the child receives prompt medical attention and assessment for anaphylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The presence of leukocytes, nitrates, and blood in the urine, along with a urinary pH of 6.5, is suggestive of a urinary tract infection (UTI). Additionally, symptoms such as frequent urination, pain or discomfort during urination, or other urinary symptoms may also be present in UTIs.
The other options (A, B, and D) are less likely based on the provided information:
A. Nephrotic syndrome typically presents with significant proteinuria and edema but may not show the specific findings seen in a UTI urinalysis.
B. Acute glomerulonephritis may have different urinalysis findings, including hematuria and proteinuria, but the presence of nitrates and leukocytes in the urine is not a typical feature.
D. Diabetes mellitus Type 1 may have glucose in the urine, but the presence of nitrates, leukocytes, and blood in the urine is more indicative of a UTI than diabetes.
Correct Answer is A
Explanation
Infants with congenital heart defects, including VSD, may have increased caloric needs due to the added work of their hearts. Congestive heart failure can lead to poor weight gain and failure to thrive. Therefore, increasing the caloric density of the formula is a common approach to providing the necessary nutrition for growth and development. This can be achieved by using specialized high-calorie infant formulas or fortifying breast milk.
The other options are not the primary supportive measures for an infant with congestive heart failure in this context:
B. Oxygen therapy to ensure oxygen saturation is > 98%: While oxygen therapy may be necessary for infants with congenital heart defects, it is not the primary supportive measure to address failure to thrive. Oxygen therapy primarily aims to ensure adequate oxygenation but does not directly address caloric intake.
C. Sedatives to keep the infant from crying: The use of sedatives is not a typical approach to managing congestive heart failure in infants. Addressing the underlying cause, optimizing nutrition, and providing supportive care are more appropriate strategies.
D. Emergent surgical correction of the defect: Surgical correction of a VSD is typically considered for specific indications, such as significant hemodynamic compromise, but it is not the first-line intervention for all cases of VSD, especially if the primary concern is failure to thrive. Treatment decisions for VSD are made based on the specific clinical presentation and severity of the defect.
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