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?
heart rate 162/min
negative doll's eye reflex.
Sunken anterior fontanel
potassium 5.1MEq/L
The Correct Answer is C
The correct answer is choice c. Sunken anterior fontanel.
Choice A rationale:
A heart rate of 162/min in a 2-month-old infant can be within the upper range of normal, especially if the infant is crying or agitated. While it is important to monitor, it is not the most critical finding in this context.
Choice B rationale:
A negative doll’s eye reflex (oculocephalic reflex) can indicate neurological issues, but it is not directly related to heart failure or the administration of furosemide.
Choice C rationale:
A sunken anterior fontanel indicates dehydration, which is a critical concern for an infant receiving furosemide, a diuretic that can lead to significant fluid loss. Dehydration can exacerbate heart failure and lead to severe complications.
Choice D rationale:
A potassium level of 5.1 mEq/L is slightly elevated but not immediately life-threatening. It requires monitoring and potential intervention but is not the most urgent issue compared to dehydration.
Monitoring for dehydration is crucial in infants on diuretics like furosemide, making the sunken anterior fontanel the priority finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
During early adolescence, children often experience mood swings. This is due to the hormonal changes that occur during this stage of development.
Correct Answer is C
Explanation
Question 1: The correct answer is Choice c. Perform developmental testing for delays.
Lead poisoning can lead to cognitive, behavioral, and developmental impairments, making developmental testing crucial for assessing potential delays and planning interventions. Developmental testing allows healthcare providers to identify any areas of concern early on, enabling them to implement appropriate interventions to support the child's development and mitigate the effects of lead poisoning.
Choice A rationale: Obtaining a stool specimen for lead levels is not the appropriate action in this scenario. Lead poisoning is typically assessed through blood lead levels, not stool specimens. Stool specimens are more commonly used for assessing gastrointestinal issues or infections rather than lead levels.
Choice B rationale: Initiating a low-iron diet for lead absorption is not recommended. Iron deficiency can actually increase lead absorption in the body, so reducing iron intake could potentially exacerbate the issue. Instead, ensuring an adequate intake of iron-rich foods may be beneficial for overall health but is not a primary intervention for lead poisoning.
Choice D rationale: Inspecting the skin for discoloration is not a relevant action for assessing lead poisoning. While lead poisoning can manifest in various symptoms, skin discoloration is not typically associated with lead exposure. Other signs and symptoms such as cognitive, behavioral, and developmental impairments are more indicative of lead poisoning.
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