A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

Initiate contact precautions.

Perform chest percussion and postural drainage.

Encourage clear liquids by mouth.

Administer IV antibiotics.

Answer and Explanation

The Correct Answer is A

A. Initiate contact precautions: RSV is a highly contagious respiratory virus spread via droplets and direct contact. To prevent transmission to others, contact precautions should be initiated.
B. Perform chest percussion and postural drainage: While these techniques can be used in some respiratory conditions, they are not the first-line intervention for RSV.
C. Encourage clear liquids by mouth: While oral rehydration may be appropriate in some cases of mild dehydration, this infant is likely experiencing respiratory distress, and oral intake may be difficult. Intravenous fluids may be required, especially if the infant is having difficulty feeding.
D. Administer IV antibiotics: RSV is caused by a virus, not a bacterial infection, so antibiotics are not effective in treating the infection.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Cough

Hypertrophic Pyloric Stenosis: Pyloric stenosis typically causes forceful vomiting but does not cause coughing.
Gastroesophageal Reflux: Coughing can occur due to aspiration or irritation of the esophagus.

Recurrent Emesis

Hypertrophic Pyloric Stenosis: Projectile vomiting after feedings is a hallmark sign of pyloric stenosis.
Gastroesophageal Reflux: GER can also cause recurrent vomiting, though it is usually less forceful than in pyloric stenosis.

Inadequate Weight Gain

Hypertrophic Pyloric Stenosis: The inability to retain feedings can lead to poor weight gain.
Gastroesophageal Reflux: Reflux can also result in poor weight gain if feedings are frequently vomited.

Irritability

Hypertrophic Pyloric Stenosis: Hunger due to inadequate feeding can cause irritability.
Gastroesophageal Reflux: Discomfort from esophageal irritation can lead to irritability.

A. "if our baby vomits after the feeding, we should administer another dose." B. "We should expect our baby to urinate less frequently while taking this medicine." C. "We should position our baby flat on their back to administer the medication." D. "We should avoid diluting the medicine in a bottle of formula." E. "We can use a medication syringe to place small amounts of medicine into the side of our baby's mouth."

Correct Answer is ["D","E"]

Explanation

A. If the baby vomits, do not administer another dose without consulting the provider to avoid overdosing.
B. There is no expected reduction in urination with GER medications. If decreased urination occurs, it may indicate dehydration or another issue.
C. The baby should not be positioned flat when administering medication to avoid choking or aspiration.
D. Avoid diluting medication in a formula bottle, as the infant may not finish the bottle, leading to incomplete dosing.
E. Administering medication with a syringe ensures accurate dosing and avoids wasting the medicine.

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A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 4-month-old infant in the outpatient setting. Exhibits For each assessment finding, click to specify if the finding is consistent with hypertrophic pyloric stenosis or gastroesophageal reflux. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

The nurse is continuing to care for the infant. Exhibits The nurse has provided teaching to the parents about the prescribed medication. Which of the following statements by the parents indicate an understanding of the teaching? Select all that apply.

Correct Answer is ["D","E"]

Explanation

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