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 A
Explanation
Choice A rationale
Emptying the bladder prior to amniocentesis reduces the risk of bladder puncture during the procedure. A full bladder could also displace the uterus, making needle insertion more challenging and increasing the potential for complications. This anatomical consideration ensures a safer and more accurate procedure for both mother and fetus.
Choice B rationale
Refraining from sexual intercourse for 48 hours prior to the procedure is not a standard or necessary instruction for an amniocentesis. While pelvic rest might be advised in certain high-risk pregnancies or after procedures that could compromise cervical integrity, it is not a general prerequisite for this diagnostic test.
Choice C rationale
Showering with an antibacterial soap the night before the procedure is a general hygienic practice but is not specifically required for an amniocentesis. While aseptic technique is paramount during the procedure itself, a special antibacterial shower beforehand is not a standard protocol to prevent infection in this context.
Choice D rationale
Taking an enema the morning of the procedure is not indicated for an amniocentesis. Enemas are typically used to clear the bowel for gastrointestinal procedures or to relieve constipation. There is no physiological or procedural benefit to bowel evacuation prior to an amniocentesis.
Correct Answer is A
Explanation
Choice A rationale
Monitoring serum electrolytes is the top priority for an infant with congenital adrenal hyperplasia (CAH). This condition involves an enzymatic defect that impairs cortisol and aldosterone synthesis, leading to salt wasting due to insufficient aldosterone. This can cause life-threatening hyponatremia and hyperkalemia, requiring urgent intervention. Normal ranges are typically sodium 135-145 mEq/L and potassium 3.5-5.0 mEq/L.
Choice B rationale
Checking for hypothermia is important for any neonate or infant, as they have immature thermoregulation. While a general nursing intervention, it is not the most specific or life-threatening concern directly related to the pathophysiology of congenital adrenal hyperplasia, which primarily involves electrolyte imbalances.
Choice C rationale
Assessing for urinary tract infection is a relevant general health assessment, especially in infants with ambiguous genitalia, due to potential anatomical variations. However, while important for overall health, it does not address the immediate, life-threatening metabolic derangements associated with congenital adrenal hyperplasia.
Choice D rationale
Recording daily weights is crucial for assessing fluid balance in infants, particularly those at risk for dehydration or fluid retention. While important for monitoring overall health and fluid status, it is secondary to the critical need to monitor and correct acute electrolyte imbalances that can rapidly become life-threatening in CAH.
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