A nurse is caring for a child who received an initial dose of antibiotics 20 minutes ago.Which of the following findings is the priority to report to the provider?
Increased pulse.
Wheezing.
Maculopapular rash.
Headache.
The Correct Answer is B
Choice A rationale
An increased pulse can be a sign of many conditions and is not as immediately alarming in the context of a potential allergic reaction as respiratory symptoms.
Choice B rationale
Wheezing is the priority finding because it indicates airway constriction, a hallmark of anaphylaxis, which is a severe and potentially life-threatening allergic reaction requiring immediate treatment.
Choice C rationale
A maculopapular rash can be a sign of an allergic reaction, but it is not immediately life-threatening like airway constriction. It should be reported but is not the priority.
Choice D rationale
A headache can be a symptom of many non-emergent conditions and does not indicate an immediate risk to the child's airway or circulation. It requires attention but is not the priority in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The heel is the recommended site for a heel stick in infants. The heel area has fewer nerve endings and a sufficient capillary bed for blood collection, making it the safest and most effective location.
Choice B rationale
The toe is not recommended for a heel stick as it has more nerve endings, which can cause more pain and discomfort for the infant.
Choice C rationale
The ankle is not an appropriate site for a heel stick due to the presence of fewer capillaries and increased risk of injury to underlying structures.
Choice D rationale
The sole of the foot is not recommended for a heel stick as it is more painful and less effective in obtaining an adequate blood sample compared to the heel. .
Correct Answer is A
Explanation
Choice A rationale
Ibuprofen should be clarified before administration to a 5-month-old infant. Ibuprofen is not recommended for infants younger than 6 months due to the risk of adverse effects on the kidneys and gastrointestinal tract. Infants have immature renal function, and administering ibuprofen can increase the risk of nephrotoxicity. Additionally, ibuprofen can cause gastric irritation and increase the risk of gastrointestinal bleeding. The nurse should verify the safety and appropriateness of this medication with the prescribing healthcare provider before administration.
Choice B rationale
Acetaminophen is generally considered safe for use in infants to reduce fever and alleviate pain. It is often the preferred antipyretic for infants younger than 6 months due to its favorable safety profile. Acetaminophen does not have the same risks of nephrotoxicity and gastrointestinal irritation as ibuprofen, making it a suitable choice for managing fever in this age group.
Choice C rationale
The heart rate of 84/min is within the normal range for a 5-month-old infant. Heart rate itself is not a medication and does not require clarification. Instead, it is a vital sign that should be monitored to assess the infant's overall condition and response to treatment.
Choice D rationale
Temperature itself is not a medication and does not require clarification. It is a vital sign that indicates the body's response to infection or inflammation. The nurse should monitor the infant's temperature and provide appropriate interventions, such as antipyretics like acetaminophen, to manage fever. .
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