A nurse is caring for a 6-week-old infant.
The Correct Answer is []
Condition Most Likely Experiencing: C
Actions to Take: A, B
Parameters to Monitor: B, C
Rationale:
Condition Most Likely Experiencing
A. Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
B. Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
C. The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.
D. Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.
Actions to Take
A. Digoxin is a medication commonly prescribed to manage congestive heart failure in infants by improving cardiac contractility and reducing heart rate.
B. Elevating the head of the bed helps reduce venous return to the heart, thereby decreasing preload and relieving symptoms of congestion in congestive heart failure.
C. Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
D. Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.
Parameters to Monitor
A. Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
B. Monitoring intake and output is crucial in assessing fluid balance, especially in congestive heart failure where fluid retention can lead to volume overload.
C. Monitoring respiratory status is essential in congestive heart failure to assess for signs of pulmonary congestion and respiratory distress, such as tachypnea, retractions, and crackles.
D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Facial twitching could indicate a neurological problem, such as a seizure, which requires immediate attention in a child with sickle cell anemia, who is at increased risk for neurological complications.
B. Kyphosis is a chronic issue and not an acute concern in sickle cell anemia.
C. Constipation is common in children with sickle cell anemia, but it is not as urgent as facial twitching.
D. Enuresis (bedwetting) is a common issue for children with sickle cell anemia but is not as immediately concerning as facial twitching, which may suggest a more urgent issue.
Correct Answer is B
Explanation
A. Hypertension is not typically associated with NEC. In fact, hypotension can occur in severe cases due to shock or sepsis.
B. Rounded abdomen is a common finding in infants with necrotizing enterocolitis (NEC). This is due to abdominal distention, which occurs as a result of gas and fluid buildup in the intestines, a characteristic feature of NEC.
C. While vomiting can be a symptom of NEC, it is not as definitive or characteristic as abdominal distention (rounded abdomen). Vomiting may occur due to bowel obstruction or ileus.
D. Tachypnea can occur in infants with NEC due to infection or sepsis, but it is not as specific or defining as the rounded abdomen.
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