A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take?

Limit oral feedings to 30 min in length.

Weigh the infant every other day.

Place the infant in the prone position for naps.

Check the infant’s oxygen saturation every 6 hr.

Answer and Explanation

The Correct Answer is A

This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in a prone position can compromise respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.

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Correct Answer is D

Explanation

This is because placing a wedge under one of the hips can help prevent compression of the inferior vena cava by the uterus, which can compromise placental blood flow and cause fetal hypoxia. Placing a wedge under the hip can also help reduce the risk of maternal hypotension, which can also affect fetal oxygenation.
Choice A is wrong because inserting a pillow under the client’s knees can increase the risk of thromboembolism, which is a potential complication of cesarean birth.
Choice B is wrong because positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration, which is another potential complication of cesarean birth.
Choice C is wrong because assisting the client into the lithotomy position can also compress the inferior vena cava and reduce placental blood flow. The lithotomy position is also not necessary for cesarean birth, as the baby is delivered through an incision in the abdomen and uterus.

A. Potassium level. B. Temperature. C. WBC count. D. Breath sounds. E. Blood pressure.

Correct Answer is ["B","C","D"]

Explanation

B, C, and D. These findings require follow-up because they indicate possible complications of chemotherapy, such as infection, low blood cell counts, and lung damage.

Choice B is correct because a temperature of 38.6° C (101.5° F) is a sign of fever, which can indicate an infection. Chemotherapy can weaken the immune system and make the client more prone to infections.

Choice C is correct because a WBC count of 3,800/mm3 is below the normal range of 5,000 to 10,000/mm3 and indicates leukopenia, a condition of low white blood cells. Chemotherapy can cause leukopenia by damaging the bone marrow where blood cells are produced.

Choice D is correct because crackles heard at the bases of the lungs are abnormal breath sounds that can indicate fluid accumulation or inflammation in the lungs. Chemotherapy can cause lung damage by affecting the cells that line the airways or by triggering an immune response.

Choice A is wrong because a potassium level of 3.6 mEq/L is within the normal range of 3.5 to 5 mEq/L and does not require follow-up.

Choice E is wrong because a blood pressure of 114/56 mm Hg is within the normal range of less than 120/80 mm Hg and does not require follow-up.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says. "Why don't you just leave me? I am of no use.”

A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client Exhibits A nurse is reviewing the client's electronic medical record. Which of the following findings requires follow-up? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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