A nurse is caring for a 2-month-old infant with heart failure. Which of the following actions should the nurse take?
Limit oral feedings to about 30 minutes in length
Check the infant’s oxygen saturation every 6 hours
Weigh the infant every other day
Place the infant in the prone position for naps
The Correct Answer is A
A. Correct – Infants with heart failure experience fatigue during feeding, leading to poor weight gain. Limiting feeding time reduces energy expenditure.
B. Incorrect – Oxygen saturation should be checked more frequently than every 6 hours, especially if the infant has cyanosis or respiratory distress.
C. Incorrect – Daily weight monitoring is necessary to assess fluid status and nutritional intake.
D. Incorrect – The infant should be placed on their back for naps to prevent sudden infant death syndrome (SIDS).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Acetaminophen is used to treat fever (pyrexia), but in hyperthermia, external cooling measures are more effective.
B. Hyperthermia can cause neurological complications, including seizures, so precautions such as padded side rails should be in place.
C. Ice water immersion can cause vasoconstriction and shivering, worsening hyperthermia.
D. A thermal blanket generates heat and is contraindicated in hyperthermia.
Correct Answer is D
Explanation
A. The shoulders are not the best place to assess cyanosis, as they may not show noticeable color changes.
B. Areas of trauma may show bruising or discoloration unrelated to cyanosis.
C. The sacrum is not the most visible site for assessing cyanosis in dark-skinned individuals.
D. The palms of the hands, soles of the feet, mucous membranes, and conjunctiva are the best areas to assess cyanosis in dark-skinned clients, as changes in oxygenation are more apparent in these regions.
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