A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?
Reactions to any previous hospitalizations.
A history of rubella, rubeola, or chicken pox.
Mother's use of alcohol, drugs, or cigarettes during pregnancy.
List of achievement timeline for developmental milestones.
The Correct Answer is C
A. Reactions to any previous hospitalizations can provide some insight into the child's previous healthcare experiences, but it may not be as directly relevant to planning care for an umbilical hernia repair.
B. A history of rubella, rubeola, or chicken pox is important for the child's medical history, but it may not be the most critical information when planning care for an umbilical hernia repair.
C. The mother's use of alcohol, drugs, or cigarettes during pregnancy is particularly relevant when planning care for a child undergoing surgery, as it can affect the child's overall health and potential complications during and after the procedure. Exposure to these substances during pregnancy can lead to various health issues that need to be considered in the child's care plan.
D. A list of achievement timeline for developmental milestones is important for understanding the child's developmental progress, but it may not be the primary consideration when planning care for an umbilical hernia repair.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assessing for teeth clenching or grinding is not the most appropriate assessment in this situation. While teeth clenching or grinding may indicate discomfort or anxiety, it may not directly address the specific concern of post-operative bleeding after a tonsillectomy.
B Inspect the posterior oropharynx.
Observing a child who has had a tonsillectomy frequently swallowing may raise concerns about post-operative bleeding. Inspecting the posterior oropharynx is essential to assess for any signs of bleeding, such as fresh blood or bleeding sites.
C. Asking the child to speak to evaluate a change in voice tone is not the primary assessment needed in this scenario. The primary concern is to assess for any signs of bleeding, and this can be done by inspecting the posterior oropharynx.
D. Touching the tonsillar pillars to stimulate the gag reflex is not necessary and may not be well-tolerated by the child who has had a tonsillectomy. It's also not the primary assessment to address the concern of post-operative bleeding.
Correct Answer is B
Explanation
A. Evaluating the infant for failure to thrive (FTT) is not the most appropriate initial intervention in this case. FTT is a long-term growth issue, and the immediate concern is the infant's current symptoms and cardiac status.
B. Auscultate heart and lungs while the infant is held.
Tetralogy of Fallot (TOF) is a congenital heart defect that includes four specific cardiac abnormalities, and it often requires surgical correction in infancy. When an infant with a history of TOF surgery presents with symptoms such as rapid breathing, feeding difficulties, and fatigue, it may raise concerns about potential cardiac issues or complications.
The most appropriate initial intervention is to auscultate the infant's heart and lungs while the infant is held to assess for any abnormal heart sounds or signs of respiratory distress. Auscultation can provide important information about the infant's cardiac and respiratory status. This assessment will help determine if there are any immediate concerns related to the infant's cardiac condition.
C. Stimulating the infant to cry to produce cyanosis is not a recommended or appropriate intervention. Cyanosis is a sign of inadequate oxygenation and should not be induced in a child.
D. Obtaining a 12-lead electrocardiogram may be indicated if there are significant concerns about the infant's cardiac status, but auscultation should be performed first to assess the immediate condition. An electrocardiogram is a diagnostic tool and would be ordered as a follow-up assessment if needed.
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