A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide.
Which of the following findings is the nurse's priority?
Negative doll's eye reflex
Sunken anterior fontanel
Potassium 5.1 mEq/L
Heart rate 162/min
The Correct Answer is D
A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.
B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement indicates understanding. Giving water after administering digoxin helps ensure that the medication is swallowed and reaches the stomach, which is important for proper absorption.
B. Giving digoxin with foods high in fiber is not a specific instruction for administering this medication. It is important to follow the healthcare provider's specific dosing
instructions.
C. If a child vomits after taking digoxin, the parent should not give another dose. They should wait until the next scheduled dose. Double dosing can lead to overdose.
D. Mixing digoxin with juice is not recommended, as it may affect the absorption of the medication. It is best to give digoxin with a small amount of water.
Correct Answer is C
Explanation
A. There is no need to seal soft toys in a plastic bag for 14 days as impetigo is not typically spread through inanimate objects. However, it is important to discourage the child from scratching the lesions to prevent further spread.
B. Soaking hairbrushes in boiling water is not necessary for the management of impetigo.
Impetigo is caused by bacteria, not lice, so boiling hairbrushes is not a standard recommendation for this condition.
C. This is the correct instruction. Applying a bactericidal ointment (e.g., mupirocin) to the impetigo lesions is a common treatment approach. This helps to eliminate the bacteria causing the infection and promote healing.
D. Administering acyclovir is not indicated for impetigo. Acyclovir is an antiviral
medication used to treat viral infections, such as herpes simplex virus. Impetigo is caused by bacterial infection, not a virus.
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