A nurse on the pediatric unit is caring for an Infant.
Drag words from the choices below to fill in each blank in the following sentence.
It would be a priority for the nurse to
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
The infant with Tetralogy of Fallot is showing signs of clinical deterioration, including worsening hypoxia, fever, hypotension, decreased urine output, and increasing lethargy. The infant’s decreasing oxygen saturation, irregular respirations, and poor perfusion suggest worsening tissue oxygenation and possible progression toward shock or hypoxic crisis. In pediatric cardiac conditions, especially cyanotic heart defects, airway, breathing, and circulation take priority, with immediate emphasis on oxygenation and vascular access for emergency management.
Rationale for correct choices:
• Apply 100% oxygen via facemask: Applying high-concentration oxygen is the immediate priority because the infant is experiencing worsening hypoxemia, as evidenced by declining oxygen saturation, cyanosis, and respiratory distress. In Tetralogy of Fallot, oxygen delivery to tissues is already compromised due to right-to-left shunting, and acute illness can further worsen hypoxia. Oxygen administration helps maximize available oxygen in the bloodstream and reduce systemic hypoxic stress.
• Initiate a peripheral IV: Establishing IV access is critical because the infant is showing signs of systemic instability, including hypotension, fever, decreased urine output, and lethargy. IV access allows for rapid administration of fluids, antipyretics, antibiotics if infection is suspected, and emergency medications if deterioration continues. In pediatric emergencies, vascular access is essential for correcting perfusion deficits and supporting circulation.
Rationale for incorrect choices:
• Administer acetaminophen: Although the infant has a fever, antipyretic administration is not the immediate priority in the presence of respiratory distress, hypoxia, and poor perfusion. Fever may be contributing to increased metabolic demand, but correcting oxygenation and circulation takes precedence. Administering acetaminophen does not address the life-threatening hypoxia or potential shock state. It can be considered after stabilization of airway, breathing, and circulation.
• Auscultate breath sounds: Assessment of breath sounds is important but is not a priority intervention at this stage because the infant already shows clear signs of systemic deterioration requiring immediate action. Respiratory assessment provides useful data, but delaying oxygen therapy and vascular access could worsen outcomes. In rapidly deteriorating pediatric patients, treatment interventions take priority over additional assessments once critical instability is identified.
• Reassure the parent: Providing reassurance is important for family-centered care, but it is not a priority in a life-threatening situation involving hypoxia and potential shock. The infant is demonstrating worsening oxygen saturation, hypotension, and decreased responsiveness, which require immediate intervention. While communication with the parent should occur, it must not delay oxygen administration or IV access.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Chemotherapy-induced oral ulcers (mucositis) occur due to damage to rapidly dividing mucosal cells in the oral cavity, leading to pain, inflammation, and increased risk of infection. In toddlers, this condition can significantly affect feeding, hydration, and comfort. Nursing care focuses on maintaining oral hygiene, reducing pain, and preventing secondary infection while avoiding irritants that may worsen mucosal injury. Gentle, non-irritating oral care is essential for promoting healing.
Rationale:
A. Cleansing the gums with saline soaked gauze is appropriate because normal saline is gentle, non-irritating, and helps maintain oral hygiene without damaging fragile mucosal tissue. It removes debris and reduces bacterial load, which lowers the risk of infection while promoting comfort and healing. This is a safe and effective intervention for chemotherapy-related mucositis.
B. Administering oral viscous lidocaine is not routinely recommended in young children because it can impair swallowing and gag reflex, increasing the risk of aspiration. Additionally, excessive use may lead to systemic toxicity due to absorption through inflamed mucosa. Safer pain management strategies are typically preferred in toddlers.
C. Scheduling routine oral care every 8 hours is insufficient because oral mucositis requires more frequent gentle care to prevent plaque buildup and infection. Oral hygiene is usually recommended multiple times per day, especially after meals and as tolerated. Infrequent care may allow worsening of discomfort and bacterial growth.
D. Moisten the mucosa with lemon glycerin swabs is contraindicated because acidic and glycerin-based solutions can further irritate already inflamed oral tissues. Lemon products may worsen pain and delay healing in mucositis. These swabs are no longer recommended for oral care in chemotherapy patients due to their drying and irritating effects.
Correct Answer is D
Explanation
Rubeola (measles) is a highly contagious viral respiratory infection caused by the measles virus, characterized by fever, cough, coryza, conjunctivitis, and a maculopapular rash. It spreads through airborne transmission and requires strict infection control measures to prevent outbreaks. Management is primarily supportive, with a strong emphasis on isolation to limit transmission during the infectious period. Nursing care focuses on symptom relief, monitoring for complications, and enforcing appropriate precautions.
Rationale:
A. Administering antiviral medication is not a standard treatment for rubeola because it is a viral illness that is primarily managed with supportive care. There is no routinely recommended specific antiviral therapy for uncomplicated measles. Treatment focuses on hydration, fever control, and prevention of complications such as pneumonia or encephalitis.
B. Providing humidified oxygen may be necessary only if the child develops respiratory complications such as severe pneumonia or hypoxia. However, it is not a routine intervention for all children with rubeola. Most cases are managed with supportive respiratory care unless significant respiratory distress is present.
C. Placing the child in a cool bath is not appropriate because it does not address the underlying infection and may increase discomfort or chills. Fever management in rubeola is achieved using antipyretics and maintaining a comfortable environment rather than aggressive cooling methods. Care should prioritize comfort and infection control rather than temperature shock.
D. Isolation until the fifth day of the rash is essential because rubeola is highly contagious from four days before to four days after rash onset. Maintaining airborne precautions and isolating the child during this period helps prevent transmission to others. This intervention is critical in controlling the spread of infection within healthcare and community settings.
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