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A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings should the nurse expect? (Select all that apply)

A.

Anoxia

B.

Frothy saliva

C.

Apnea

D.

Sunken abdomen

Answer and Explanation

The Correct Answer is B

Choice A: Anoxia

Reason: Anoxia refers to an absence of oxygen supply to an organ or a tissue. While it is a serious condition, it is not a typical finding specifically associated with tracheoesophageal fistula (TEF). TEF primarily affects the esophagus and trachea, leading to issues with feeding and breathing, but not directly causing anoxia. Anoxia could be a secondary complication if the infant experiences severe respiratory distress, but it is not a primary symptom.

Choice B: Frothy Saliva

Reason: Frothy saliva is a common and significant finding in infants with tracheoesophageal fistula. This occurs because the abnormal connection between the trachea and esophagus allows saliva to accumulate and bubble up, leading to frothy secretions. This symptom is often one of the first signs that alert healthcare providers to the presence of TEF.

Choice C: Apnea

Reason: Apnea, or temporary cessation of breathing, is another expected finding in infants with tracheoesophageal fistula. The abnormal connection can cause aspiration of saliva or food into the lungs, leading to respiratory distress and apnea. This is a critical symptom that requires immediate medical attention to prevent severe complications.

Choice D: Sunken Abdomen

Reason: A sunken abdomen is not typically associated with tracheoesophageal fistula. In fact, infants with TEF might present with abdominal distension due to air entering the stomach through the fistula. A sunken abdomen could indicate other conditions such as dehydration or malnutrition, but it is not a characteristic finding of TEF.


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Related Questions

Correct Answer is ["5.6"]

Explanation

Calculation Steps

Step 1: Convert the toddler’s weight from pounds to kilograms.

  • 33 lbs ÷ 2.2 = 15 kg
  • Result: 15 kg

Step 2: Calculate the total daily dose of amoxicillin.

  • 30 mg/kg/day × 15 kg = 450 mg/day
  • Result: 450 mg/day

Step 3: Since the dose is divided equally every 12 hours, calculate the dose per administration.

  • 450 mg/day ÷ 2 = 225 mg/dose
  • Result: 225 mg/dose

Step 4: Determine the volume of the suspension to administer per dose.

  • 225 mg ÷ (200 mg ÷ 5 mL) = 225 mg ÷ 40 mg/mL = 5.625 mL
  • Result: 5.625 mL

Step 5: Round to the nearest tenth.

  • 5.625 mL rounds to 5.6 mL
  • Result: 5.6 mL

Therefore, the nurse should administer 5.6 mL of amoxicillin per dose.

Correct Answer is D

Explanation

Choice A Reason:

The statement “I will report a change in her breathing” is appropriate. Changes in breathing can indicate worsening of the upper respiratory infection or complications such as diabetic ketoacidosis (DKA), which requires immediate medical attention. Reporting such changes is crucial for timely intervention.

Choice B Reason:

The statement “I will notify the doctor if her temperature is not controlled with acetaminophen” is also appropriate. Persistent fever despite acetaminophen can indicate a more serious infection or other complications that need medical evaluation. This ensures that the child receives appropriate care and treatment.

Choice C Reason:

The statement “I will encourage her to drink half a cup of water or sugar-free fluids every 30 minutes” is correct. Staying hydrated is essential, especially for a child with diabetes, to prevent dehydration and help manage blood sugar levels. Sugar-free fluids are recommended to avoid spikes in blood sugar.

Choice D Reason:

The statement “I will continue to check her blood sugar two times per day when she is sick” indicates a need for further instruction. When a child with type 1 diabetes is sick, blood sugar levels can fluctuate more than usual. It is generally recommended to check blood sugar levels more frequently, such as every 3-4 hours, to ensure they remain within a safe range and to detect any signs of hyperglycemia or hypoglycemia early.

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