A nurse is caring for an infant in a provider's office.
Medical History Provider Visit #1. Heart rate 144/min.
Axillary temperature 39.7° C (103.5°F). Respiratory rate 32/min.
Oxygen saturation 95% on room air. Provider Visit #2 (4 days later).
Axillary temperature 37.4° C (99.3° F). Heart rate 132/min.
Respiratory rate 28/min.
Oxygen saturation 97% on room air.
Which of the following actions should the nurse plan to take? Select the actions the nurse should plan to take.
Teach caregivers to change diapers when wet.
Have caregivers administer 16 oz of water after each diarrhea stool.
Cleanse the diaper area with soap and water.
Collect nasal drainage for culture and sensitivity.
Teach caregivers to apply talcum powder to creases.
Use a nasal aspirator after feedings.
Correct Answer : A,G
A. Teach caregivers to change diapers when wet.
✅ Correct. Prevents skin breakdown and diaper dermatitis.
B. Have caregivers administer 16 oz of water after each diarrhea stool.
❌ Incorrect. Infants should not get plain water in such amounts. Risk of water intoxication & electrolyte imbalance. Oral rehydration solutions (ORS) or breast milk/formula are recommended instead.
C. Cleanse the diaper area with soap and water.
❌ Incorrect. Harsh soaps can irritate the skin. Best practice: gentle cleansing with warm water or mild wipes, and barrier ointment if needed.
D. Collect nasal drainage for culture and sensitivity.
❌ Incorrect. Only done if ordered and if infection is suspected. At follow-up (Visit #2), infant is afebrile and stable—no need for culture.
F. Teach caregivers to apply talcum powder to creases.
❌ Incorrect. Talcum powder is contraindicated in infants (risk of aspiration & respiratory issues). Barrier creams preferred.
G. Use a nasal aspirator after feedings.
✅ Correct. Safe and effective to clear nasal secretions and prevent aspiration or feeding difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Isotretinoin has been associated with depression and other psychiatric side effects.
The client should report any changes in mood or behavior, including feelings of isolation, to the provider immediately.
Choice B is not an answer because while frequent nosebleeds can be a side
effect of isotretinoin, it is not the priority to report to the provider.
Choice C is not an answer because while back pain can be a side effect of isotretinoin, it is not the priority to report to the provider.
Choice D is not an answer because while itching of the skin can be a side effect of isotretinoin, it is not the priority to report to the provider.
Correct Answer is C
Explanation
The correct answer is C. 2 mL/kg/hr.
Choice A rationale: An output of 0.5 mL/kg/hr is insufficient and indicative of ongoing dehydration or inadequate fluid intake.
Choice B rationale: An output of 15 mL/kg/hr is excessive and could suggest overhydration or a different pathology.
Choice C rationale: A urinary output of 2 mL/kg/hr is an ideal measure for indicating that fluid balance has been restored in infants.
Choice D rationale: An output of 7.5 mL/kg/hr is unusually high and not typical for a corrected fluid balance in infants.
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