A nurse is providing care for a 6-month-old infant who underwent a cardiac catheterization.

The child was diagnosed with pulmonary stenosis early in infancy and was admitted today for a balloon angioplasty procedure.

Which of the following should the nurse plan to include in the discharge teaching?

Apply pressure dressing four hours after discharge.

Call the provider if the patient’s leg feels cool to touch compared to the left extremity.

Administer acetaminophen or ibuprofen oral solution if needed for pain.

Maintain a clear liquid diet for 24 hours after discharge.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Applying a pressure dressing four hours after discharge is not typically recommended following a cardiac catheterization. The site of the catheter insertion is usually covered with a simple dressing and observed for any signs of bleeding or swelling.
Choice B rationale
While it’s important to monitor for signs of impaired circulation, such as a cool extremity, this is not the primary concern following a cardiac catheterization. The procedure involves inserting a catheter into a blood vessel, not typically affecting the peripheral temperature of the extremities.
Choice C rationale
Administering acetaminophen or ibuprofen for pain as needed is a common recommendation following procedures like a balloon angioplasty. Pain can result from the catheter insertion site and these medications can help manage it.
Choice D rationale
Maintaining a clear liquid diet for 24 hours after discharge is not typically necessary following a cardiac catheterization. Once the child is alert, they are usually provided with clear liquids and later something to eat.

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Correct Answer is A

Explanation

Choice A rationale
Monitoring vaginal bleeding is the priority nursing action for a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Placenta previa can cause painless, bright red vaginal bleeding during the third trimester. This bleeding can lead to serious complications for both the mother and the fetus, making it crucial to monitor for this symptom.
Choice B rationale
Administering glucocorticoids is not the priority nursing action in this situation. While glucocorticoids can be used to accelerate fetal lung maturity in cases of preterm labor, they are not the primary treatment for placenta previa.
Choice C rationale
Inserting an IV catheter may be necessary for administering medications or fluids, but it is not the priority action. The nurse’s primary concern should be monitoring for signs of bleeding.
Choice D rationale
Applying an external fetal monitor can help assess the well-being of the fetus, but it is not the priority action. The nurse’s main focus should be on monitoring for vaginal bleeding.

A. Position the infant supine. B. Initiate contact precautions. C. Ensure a latex-free environment. D. Restrict visitors to immediate family members.

Correct Answer is C

Explanation

Choice A rationale
Positioning the infant supine is not the most appropriate intervention for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac. This position could put pressure on the sac and potentially lead to rupture or infection.
Choice B rationale
While contact precautions can be important in certain situations to prevent the spread of infection, they are not the primary intervention for a child with spina bifida undergoing surgery. The main concern is protecting the myelomeningocele sac from damage and infection.
Choice C rationale
Ensuring a latex-free environment is crucial for a child with spina bifida. Many children with spina bifida have a latex allergy, and exposure to latex can cause an allergic reaction. This can range from skin redness and itching to more serious symptoms such as wheezing and difficulty breathing.
Choice D rationale
Restricting visitors to immediate family members is not specifically related to the care of an infant with spina bifida. While limiting visitors can help reduce the risk of infection, it is not the primary concern in this case.

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A nurse is providing care for a 6-month-old infant who underwent a cardiac catheterization. The child was diagnosed with pulmonary stenosis early in infancy and was admitted today for a balloon angioplasty procedure. Which of the following should the nurse plan to include in the discharge teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. What is the priority nursing action?

Correct Answer is A

Explanation

A nurse is formulating a care plan for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac. Which of the following interventions should be incorporated into the care plan?

Correct Answer is C

Explanation

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