A six-month-old infant is hospitalized for repair of a ventricular septal defect. As you are doing his physical exam, you note that the infant's extremities are cool, he has weak peripheral pulses, and his urine output is diminished. These clinical findings are suggestive of which of the following?

Increased stroke volume

Cardiac arrhythmia

Decreased cardiac output

Cyanosis

Answer and Explanation

The Correct Answer is C

Choice A reason: Increased stroke volume is not a correct answer as it means that the heart pumps more blood with each contraction. This would result in increased blood pressure and perfusion, not cool extremities, weak pulses, and low urine output.

Choice B reason: Cardiac arrhythmia is not a correct answer as it means that the heart beats irregularly or abnormally. This can cause palpitations, chest pain, or fainting, but not necessarily cool extremities, weak pulses, and low urine output.

Choice C reason: Decreased cardiac output is a correct answer as it means that the heart pumps less blood than the body needs. This can result from a ventricular septal defect, which causes blood to shunt from the left ventricle to the right ventricle, reducing the amount of oxygenated blood that reaches the tissues. This can cause cool extremities, weak pulses, and low urine output, as well as fatigue, poor growth, and shortness of breath.

Choice D reason: Cyanosis is not a correct answer as it means that the skin, lips, or nails turn blue due to low oxygen levels in the blood. This can occur in some cases of ventricular septal defect, especially if there is pulmonary hypertension or a reversal of the shunt. However, cyanosis is not a direct cause of cool extremities, weak pulses, and low urine output.

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Correct Answer is A

Explanation

Choice A reason: This is correct because the semi-Fowler's position, which is a 30 to 45 degree angle of the head of the bed, allows for optimal drainage of the surgical site and reduces the pressure on the incision. It also helps the girl breathe easier and prevents aspiration.

Choice B reason: This is incorrect because the supine position, which is lying flat on the back, can increase the pain and discomfort of the girl after the appendectomy. It can also impair the drainage of the surgical site and increase the risk of infection.

Choice C reason: This is incorrect because the prone position, which is lying on the stomach, can cause more pain and pressure on the incision site. It can also interfere with the drainage of the surgical site and increase the risk of infection.

Choice D reason: This is incorrect because the Trendelenburg position, which is a head-down tilt of the bed, can increase the intra-abdominal pressure and cause more pain and discomfort for the girl. It can also impair the venous return and cause hypotension.

A. Give the infant ibuprofen and then apply cool wet sponges to the infant. B. Give the infant acetaminophen now and call back in 2 hours if the fever has not gone down. C. Take the infant to the urgent care clinic now. D. Put the infant in a cool bath.

Correct Answer is C

Explanation

Choice A reason: This statement is incorrect, as ibuprofen is not recommended for infants under 6 months of age due to the risk of kidney damage and bleeding. Cool wet sponges can also cause shivering and increase the body temperature. The nurse should advise the father to avoid these methods and seek medical attention.

Choice B reason: This statement is incorrect, as acetaminophen is not enough to treat a high fever in a 2-month-old infant. The nurse should also inform the father that the normal dose of acetaminophen for infants is 10 to 15 mg/kg every 4 to 6 hours, and that he should not exceed 5 doses in 24 hours. The nurse should urge the father to take the infant to the urgent care clinic as soon as possible.

Choice C reason: This statement is correct, as a fever of 38.5°C (101.3°F) or higher in an infant under 3 months of age is considered a medical emergency and requires immediate evaluation and treatment. The nurse should explain to the father that a high fever in a young infant can indicate a serious infection, such as meningitis, sepsis, or urinary tract infection, and that the infant needs to be seen by a doctor right away.

Choice D reason: This statement is incorrect, as putting the infant in a cool bath can cause hypothermia and shock. The nurse should advise the father to avoid this method and seek medical attention.

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A six-month-old infant is hospitalized for repair of a ventricular septal defect. As you are doing his physical exam, you note that the infant's extremities are cool, he has weak peripheral pulses, and his urine output is diminished. These clinical findings are suggestive of which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A fourteen-year-old girl has returned to the nursing unit after undergoing an appendectomy. To help relieve pain and facilitate drainage, the nurse should place her in what position?

Correct Answer is A

Explanation

The father of a 2-month-old infant calls the advice nurse saying his child has a fever of 38.5°C (101.3°F). The nurse should instruct the father to do which of the following?

Correct Answer is C

Explanation

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