A nurse is caring for a 6-week-old infant in the pediatric unit.
Complete the diagram by dragging from the choices below to specify:
- What condition the client is most likely experiencing
- Two actions the nurse should take to address that condition
- Two parameters the nurse should monitor to assess the client’s progress
The Correct Answer is []
Actions to Take:
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Anticipate a prescription for digoxin:
- Digoxin is commonly used in pediatric heart failure cases to improve the strength of the heart’s contractions, helping to increase cardiac output and reduce symptoms of CHF. The nurse should anticipate its use to help manage the infant’s heart function.
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Elevate the head of the bed to a 45° angle:
- This action helps reduce the work of breathing and decreases venous return to the heart, which can alleviate pulmonary congestion and improve respiratory function. Positioning the infant in a semi-upright position is crucial to relieve symptoms of CHF, especially when there’s evidence of respiratory distress.
Parameters to Monitor:
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Peripheral pulses:
- Monitoring peripheral pulses is essential in assessing the effectiveness of the heart’s ability to pump blood. The weak pedal pulses and bounding upper extremity pulses noted earlier are significant findings that need to be monitored to gauge improvement in circulation as the infant’s condition is managed.
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Respiratory status:
- Respiratory rate, effort (including retractions and nasal flaring), and oxygen saturation levels must be closely monitored to track the infant's progress. Improvement in respiratory status, along with reduced crackles, would indicate a reduction in pulmonary congestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Initiate airborne precautions.
Choice A rationale
Assessing the oral cavity for Koplik spots is not relevant for varicella. Koplik spots are associated with measles, not varicella. Varicella, also known as chickenpox, typically presents with a rash that starts on the trunk and spreads to the rest of the body, along with other symptoms like fever and malaise.
Choice B rationale
Administering aspirin for fever is contraindicated in children with varicella due to the risk of Reye’s syndrome. Reye’s syndrome is a rare but serious condition that can occur when aspirin is given to children with certain viral infections, including varicella. It can cause swelling in the liver and brain.
Choice C rationale
Providing the child with a warm blanket can offer comfort to the child, helping to alleviate chills or discomfort associated with fever. However, it is not a specific intervention for managing varicella. The primary focus should be on preventing the spread of the infection through appropriate precautions.
Choice D rationale
Initiating airborne precautions is essential for preventing the spread of varicella. Varicella is transmitted via airborne droplets, and using airborne precautions (such as negative air-flow rooms) helps prevent the spread of the virus to other patients and healthcare workers. If negative air-flow rooms are not available, isolating patients in closed rooms with no contact with people without evidence of immunity is recommended.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Serous chest tube drainage is a normal finding and does not typically indicate a complication. It is usually clear or pale yellow fluid that is expected after surgery.
Choice B rationale
Chest tube drainage of 200 mL in 1 hour is excessive and should be reported to the provider. This could indicate active bleeding or other complications that require immediate attention.
Choice C rationale
Fluctuation in the water-sealed chamber, also known as tidaling, is a normal finding and indicates that the chest tube is functioning properly. It reflects changes in pressure within the pleural space during respiration.
Choice D rationale
A respiratory rate of 22/min is within the normal range for a school-age child and does not typically indicate a complication.
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