An infant with bronchiolitis is taken to the clinic. The infant is congested and febrile with a capillary refill time of 2 seconds.
Which information should the practical nurse (PN) reinforce with the infant's caregiver?
Place infant on back for naps.
Encourage the infant to play.
Limit intake of oral fluids.
Isolate infant from others.
The Correct Answer is D
Choice A rationale
Placing an infant on their back for naps is a critical recommendation to reduce the risk of Sudden Infant Death Syndrome (SIDS), but it is not directly related to managing bronchiolitis symptoms or preventing its spread. While generally good advice, it doesn't address the acute respiratory infection.
Choice B rationale
Encouraging the infant to play might be detrimental during an acute febrile illness like bronchiolitis. Increased physical activity can increase oxygen demand and exacerbate respiratory distress in an infant whose respiratory system is already compromised, potentially worsening their clinical condition.
Choice C rationale
Limiting intake of oral fluids would be counterproductive for an infant with bronchiolitis and fever. Adequate hydration is crucial to thin respiratory secretions, facilitate expectoration, and prevent dehydration, especially with fever, which increases insensible fluid losses. Maintaining hydration supports recovery.
Choice D rationale
Isolating the infant from others is a crucial measure to prevent the spread of respiratory syncytial virus (RSV), the most common cause of bronchiolitis, to susceptible individuals. RSV is highly contagious, and isolation helps protect other children and adults, particularly those with compromised immune systems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Describing the percentage of saturated perineal pads is a subjective and imprecise method for estimating blood loss. Variations in pad size, absorbency, and the client's perception can lead to significant inaccuracies, making it unreliable for precise clinical assessment of hemorrhage.
Choice B rationale
While hematocrit levels are crucial for assessing overall blood volume status, obtaining an hourly hematocrit is an indirect and reactive measure of acute blood loss. It reflects hemodilution or hemoconcentration over time rather than providing a real-time, accurate quantification of the volume of blood lost. Normal hematocrit for pregnant women is 33% to 44%.
Choice C rationale
Changes in vital signs, such as tachycardia, hypotension, and tachypnea, are late indicators of significant blood loss and hypovolemic shock. Relying solely on vital signs means that a substantial amount of blood has already been lost before changes become apparent, making it an insensitive method for early detection and estimation.
Choice D rationale
Calculating the difference in weight of perineal pads before and after use provides a highly accurate objective measurement of blood loss. One gram of weight is approximately equivalent to one milliliter of blood, allowing for precise quantification and enabling timely and appropriate clinical interventions.
Correct Answer is D
Explanation
Choice A rationale
Cheese is a good source of calcium and protein, but it is not a primary source of iron. Iron is essential for hemoglobin synthesis, and the client's hemoglobin and hematocrit levels are below normal ranges [Hemoglobin, pregnant female > 11 g/dL ( > 110 g/L); Hematocrit, pregnant female > 33% ( > 0.33 volume fraction)], indicating iron deficiency anemia.
Choice B rationale
Cauliflower is a cruciferous vegetable rich in vitamin C and fiber, but its iron content is relatively low. While vitamin C aids in iron absorption, cauliflower itself does not provide a significant amount of dietary iron to effectively address the client's anemic status.
Choice C rationale
Carrots are well-known for their beta-carotene content, a precursor to vitamin A, and provide fiber. However, carrots are not a significant source of iron. To combat iron deficiency anemia during pregnancy, foods rich in heme iron or non-heme iron with good bioavailability are required.
Choice D rationale
Chicken, particularly the dark meat, is a good source of heme iron, which is more readily absorbed by the body compared to non-heme iron found in plant-based foods. Given the client's anemic status, increasing dietary intake of iron-rich foods like chicken is crucial for improving hemoglobin and hematocrit levels.
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