A nurse is caring for an infant with respiratory syncytial virus (RSV). Which of the following are appropriate nursing interventions when prioritizing care for an infant with RSV? (Select All that Apply.)
Encouraging the infant to engage in vigorous physical activity
Administering antibiotics to treat the viral infection
Isolating the infant to prevent the spread of infection to other infants
Administering bronchodilators to improve respiratory function
Providing frequent small, age-appropriate feedings to prevent dehydration
Administering oxygen to maintain adequate oxygen saturation levels
Correct Answer : C,D,E,F
A. Encouraging vigorous physical activity is not appropriate for an infant with RSV, as it can worsen respiratory distress.
B. Antibiotics are not effective against RSV because it is a viral infection. Antibiotics should only be used for secondary bacterial infections.
C. Isolation is crucial to prevent the spread of RSV to other infants, especially in healthcare settings.
D. Bronchodilators may be used to help open the airways and ease breathing in some cases of RSV.
E. Small, frequent feedings are important to prevent dehydration, as infants with RSV may struggle with feeding due to difficulty breathing.
F. Oxygen therapy is often required to maintain adequate oxygen levels in infants with RSV, particularly if they are experiencing respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pyloric stenosis typically causes projectile vomiting shortly after feedings. After vomiting, the infant may still appear hungry and may want to feed again. This is because the blockage prevents food from entering the small intestine, causing the infant to feel hungry soon after vomiting.
B. One of the classic physical findings of pyloric stenosis is a palpable "olive-shaped" mass in the upper abdomen, which is usually located in the right upper quadrant. This mass is the enlarged pyloric muscle.
C. Jelly-like stools are more characteristic of intussusception, not pyloric stenosis.
D. While the child may show signs of discomfort or irritability due to hunger, severe pain in the abdomen is not a hallmark of pyloric stenosis.
Correct Answer is []
Explanation
Potential condition- Intussusception
Intussusception is a condition where one part of the intestine folds into another part, causing an obstruction. It is common in infants and toddlers and typically presents with the following signs- Severe abdominal pain, which causes the child to pull their knees to their chest (classic sign of colicky abdominal pain), red, jelly-like stools (which indicate the presence of blood and mucus in the stool) and palpable mass in the right upper quadrant (which could be the telescoping portion of the bowel).
Actions to Take
- Place child on NPO status:
The child should be placed on nothing by mouth (NPO) status to prepare for potential procedures, such as an enema or surgery. This prevents aspiration during any intervention and ensures the bowel is not further irritated by food or liquid intake.
- Prepare child for an air enema:
Air enema is a non-invasive treatment for intussusception. It is often used to reduce the telescoping bowel by using air under fluoroscopic guidance. This treatment can resolve the condition in many cases without the need for surgery. The nurse must ensure the child is properly prepared for this procedure (e.g., ensuring the child is NPO, monitoring vitals, and explaining the procedure to the family).
Parameters to Monitor
- Stool patterns:
Monitoring the stool patterns is essential to assess the progress and severity of intussusception. The presence of red, jelly-like stools (blood and mucus) is characteristic of intussusception, and any changes in stool appearance can help evaluate the effectiveness of treatment. The nurse should monitor if the stool pattern changes after the air enema or surgical intervention.
- Abdominal pain:
Abdominal pain is a hallmark symptom of intussusception, and the nurse should continually assess the child's pain level. The child may experience intermittent, severe cramp-like pain due to the bowel obstruction. Monitoring and managing the pain effectively is crucial for patient comfort and well-being.
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