A nurse is assisting with the care of a 5-month-old infant who was just admitted to the pediatric unit.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the infant.
Maintain infant on continuous pulse oximetry.
Prepare the infant for a chest x-ray.
Initiate a peripheral IV line.
Maintain infant in supine position.
Offer small, frequent feedings.
Monitor intake and output.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Continuous pulse oximetry: Anticipated because the infant has respiratory distress and requires continuous monitoring of oxygen saturation.
Chest x-ray: Anticipated to assess the extent of lung involvement due to the respiratory distress and wheezing noted.
Peripheral IV line: Anticipated since the peripheral line will be used to administer intravenous medications and fluids.
Supine position: Contraindicated because the infant prefers to sit upright and shows signs of respiratory distress, such as nasal flaring and retractions.
Small, frequent feedings: Anticipated to ensure adequate nutrition despite feeding difficulties.
Monitor intake and output: Anticipated to assess hydration status, especially since the infant has had decreased intake and output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition: Increased intracranial pressure
Actions to Take:
Measure head circumference: This action is important to monitor for signs of increasing intracranial pressure, as a bulging and tense fontanel suggests possible hydrocephalus or other intracranial pathology.
Plan to assist with administration of antibiotics: Antibiotics may be necessary if there is suspected meningitis or another infectious cause contributing to increased intracranial pressure.
Parameters to Monitor:
Behavioral changes: Monitor for irritability, difficulty to console, and other behavioral changes which can indicate neurological distress.
Pupillary response: Assess for changes in pupillary size and reactivity, as altered pupillary responses can indicate neurological involvement and increased intracranial pressure.
Correct Answer is B
Explanation
A. After administering otic medication, the child should be kept in a side-lying position on the opposite side (unaffected side) to allow the medication to flow into the ear canal properly.
B. Allowing the medication to reach room temperature before administration prevents dizziness and discomfort that can occur with cold drops. This is important for ensuring the child is comfortable and cooperates with the procedure.
C. For a 2-year-old, the ear should be gently pulled down and back to straighten the ear canal for proper administration of the medication.
D. Administering the medication with the child in an upright position is not the best method. The side-lying position allows better access to the ear canal and proper absorption of the medication.
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