A nurse in a pediatric intensive care unit is assessing a 6-month-old infant. Which of the following findings should the nurse identify as an indication of neurological impairment?
The child's oxygen saturation is 96% on room air.
The child reports pain as 8 on a scale of 0 to 10.
The child is drowsy but responds immediately to verbal stimuli.
The child's blood pressure is 100/60 mm Hg.
The Correct Answer is C
A. The child's oxygen saturation is 96% on room air. This is a normal oxygen saturation level for an infant on room air and does not indicate neurological impairment. Normal oxygen saturation levels are typically between 95% and 100%.
B. The child reports pain as 8 on a scale of 0 to 10. A 6-month-old infant cannot verbally report pain on a numeric scale. Pain assessment in infants is typically done using behavioral and physiological indicators, not a numeric scale. This choice is not relevant for this age group.
C. The child is drowsy but responds immediately to verbal stimuli. This could be an indication of neurological impairment. While infants can sleep a lot, being excessively drowsy and requiring verbal stimuli to respond could suggest an altered level of consciousness, which warrants further assessment for potential neurological issues.
D. The child's blood pressure is 100/60 mm Hg. This is within normal limits for a 6-month-old infant and does not indicate neurological impairment. Normal blood pressure for infants ranges from about 70-100/50-65 mm Hg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Encourage maintaining bilateral elbow restraints: This is not typically used for cleft palate repair. Elbow restraints might be used for other procedures.
B. Apply antibiotic ointment to the suture line for 3 days postoperatively: Applying antibiotic ointment to the suture line helps prevent infection and promotes healing. It’s essential to follow the postoperative care instructions to ensure the best outcomes for the infant.
C. Encourage use of straws when drinking fluids: Using straws can create negative pressure in the oral cavity, which may put stress on the suture line and compromise wound healing. The suction force generated during straw use can potentially disrupt the surgical site.
D. Avoid disturbing any crusts that form on the suture line: This is generally good advice to promote healing and prevent infection.
Correct Answer is C
Explanation
A. Administer antispasmodics: Antispasmodics are not typically used for vaso-occlusive crisis pain, which is usually due to ischemia and not muscle spasms.
B. Apply ice to joints: Applying ice is not recommended as it can cause vasoconstriction, worsening the sickling of cells and the pain associated with a vaso-occlusive crisis. Heat application is more appropriate to promote circulation.
C. Initiate IV fluids: Correct. Hydration is a key intervention in managing a vaso-occlusive crisis because it helps to decrease the viscosity of the blood and prevent further sickling of cells.
D. Assess for hyperkalaemia: While it is important to monitor electrolyte levels, hyperkalaemia is not directly associated with a vaso-occlusive crisis. The primary focus should be on pain management and hydration.
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