A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician of what conditions occur. (Select all that apply.).
Respiratory rate of 36 breaths/minute at rest.
Appetite slowly increasing.
Temperature above 37.7° C (100° F).
New, frequent coughing.
Turning blue or bluer than normal.
Correct Answer : A,C,D,E
The correct answer is choices A, C, D, and E.
Choice A rationale:
A respiratory rate of 36 breaths/minute at rest is concerning in a pediatric client, as it may indicate respiratory distress or an underlying respiratory condition.
Choice B rationale:
An increasing appetite is generally a positive sign and not typically concerning unless accompanied by other symptoms.
Choice C rationale:
A temperature above 37.7° C (100° F) is concerning as it indicates fever, which could be a sign of infection or other medical conditions.
Choice D rationale:
New, frequent coughing is concerning as it may indicate respiratory infections, asthma, or other respiratory issues.
Choice E rationale:
Turning blue or bluer than normal (cyanosis) is a serious symptom indicating inadequate oxygenation and requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Increasing the caloric density of an infant's formula provides more calories in a smaller volume, reducing the energy expenditure required for feeding. This approach ensures the infant receives adequate nutrition while managing heart failure symptoms effectively.
Choice B rationale: Feeding an infant every 2 hours can lead to feeding intolerance and fatigue. Infants with heart failure often have limited energy reserves and need longer intervals between feedings to conserve energy and improve feeding effectiveness.
Choice C rationale: Increasing the amount of formula per feeding can overwhelm an infant with heart failure, leading to fatigue and decreased feeding efficiency. Smaller, frequent feedings with higher caloric density are more effective in providing necessary nutrients.
Choice D rationale: Placing a nasal oxygen cannula on an infant during feeding is not a standard recommendation for managing heart failure. While oxygen therapy may be necessary for some infants, it is not specifically tied to feeding practices and should be used based on individual clinical assessments.
Correct Answer is D
Explanation
Choice A rationale:
Perinatal transmission of HIV can occur not only in the third trimester but also during labor and delivery. It is not limited to the maternal circulation alone.
Choice B rationale:
While needlestick injuries are a potential risk for healthcare workers, perinatal transmission to the newborn does not occur through this route.
Choice C rationale:
HIV is not transmitted through the ingestion of amniotic fluid. The virus can be present in the amniotic fluid, but the main route of transmission to the newborn is during delivery or through breastfeeding.
Choice D rationale:
The correct answer. HIV can be transmitted from an infected mother to her child through breastfeeding if appropriate antiretroviral therapy is not administered. Breast milk can contain the virus, putting the infant at risk of infection. Therefore, in cases where the mother is HIV-positive, formula feeding is recommended to prevent transmission of the virus to the newborn.
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