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
Related Questions
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
Choice A rationale
While it’s important for individuals with diabetes to monitor their cholesterol levels, a cholesterol level of 189mg/dl is within the acceptable range for most people.
Choice B rationale
Glycosuria, or sugar in the urine, can be a sign of poorly controlled diabetes. However, it’s not typically used as a primary indicator of diabetes control.
Choice C rationale
An HbA1c level of 11.5% is significantly higher than the target range of less than 7% for most adults with
diabetes. This suggests that the individual’s blood sugar levels have been much higher than the target range for the past 2 to 3 months17.
Choice D rationale
A pre-prandial (before meal) blood glucose level of 124mg/dL is slightly higher than the target range of 70- 130mg/dL. However, it’s not as concerning as an HbA1c level of 11.5%.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.