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 D
Explanation
Choice A rationale:
Limiting the time spent on exploration of intimate topics may result in incomplete information, leading to potential gaps in the patient's health history. It's essential to create a safe and supportive environment, allowing the patient to share necessary information freely.
Choice B rationale:
Avoiding questions that may embarrass the patient could prevent the nurse from gathering crucial information related to the patient's reproductive health. Sensitivity and non-judgmental communication are essential, enabling the patient to openly discuss sensitive topics.
Choice C rationale:
Using accepted medical terminology is important, but it should be balanced with clear communication. Complex medical terms might confuse the patient. It's essential to use language that the patient can understand, ensuring effective communication and a better understanding of their health.
Choice D rationale:
This statement indicates a correct understanding of the best approach when obtaining a reproductive health history. Explaining the purpose for the questions asked and how the information will be used builds trust and helps the patient feel more comfortable sharing sensitive information. It also ensures that the patient understands the relevance of the questions, fostering open communication between the patient and the healthcare provider.
Correct Answer is B
Explanation
Choice A rationale:
Breastfeeding mothers can receive the live attenuated rubella virus. Rubella vaccination is part of routine postpartum care for non-immune women. Breastfeeding does not interfere with the effectiveness of the rubella vaccine.
Choice B rationale:
Rubella vaccination is indeed teratogenic and can cause congenital rubella syndrome if a woman becomes pregnant within 28 days of vaccination. It is crucial for healthcare providers to educate women about the importance of avoiding pregnancy for this period after receiving the rubella vaccine to prevent potential harm to the fetus.
Choice C rationale:
Rh immune globulin (RhIg) is given to Rh-negative mothers to prevent Rh isoimmunization. It is administered intramuscularly, not intravenously. Intravenous administration of RhIg can lead to adverse reactions and is not considered a safe route for this medication. RhIg does not have any impact on the infant's immune system.
Choice D rationale:
Rh immune globulin does not boost the immune system or enhance the effectiveness of vaccinations. Its primary function is to prevent the development of antibodies in Rh-negative individuals who have been exposed to Rh-positive blood, such as during pregnancy or delivery.
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