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
Protecting the myelomeningocele surgical incision from fecal contamination is paramount to prevent infection, as the defect is often located in the lumbosacral area. Fecal matter contains a high concentration of microorganisms, and any contamination could lead to serious central nervous system infections like meningitis.
Choice B rationale
The statement that the dressing will help dry the sutures for ease of removal is incorrect. Occlusive dressings are designed to maintain a moist wound environment, which promotes optimal wound healing and reduces scar formation, rather than drying sutures for removal.
Choice C rationale
Rapidly removing tape from the edges of the dressing is an incorrect technique. This can cause skin trauma, including stripping or tearing, especially in infants whose skin is delicate. Tape should be removed slowly and parallel to the skin to minimize epidermal injury.
Choice D rationale
The statement that the dressing should be dampened periodically to keep the skin incision moist is generally incorrect for surgical incisions once an occlusive dressing is applied. The occlusive dressing itself maintains a moist environment underneath, and external dampening could introduce pathogens and compromise the sterile field.
Correct Answer is D
Explanation
Choice A rationale
Washing frequently with mild soap and water is not recommended for umbilical cord care because soap can irritate the delicate skin around the cord stump and potentially delay the natural drying and separation process. Excessive moisture also increases the risk of bacterial colonization and infection, counteracting the goal of keeping the area clean and dry to promote healing and reduce infection risk.
Choice B rationale
Applying baby lotion to the umbilical cord stump is contraindicated. Lotions introduce moisture, which can impede the natural drying and mummification of the cord, prolonging the time until it falls off. Furthermore, lotions contain chemicals that may irritate the sensitive skin or harbor bacteria, increasing the risk of infection and delaying proper healing of the umbilical area.
Choice C rationale
Covering the umbilical cord with a sterile dressing is generally not advised unless specifically indicated by a healthcare provider for a particular condition. A dressing can trap moisture, preventing adequate air circulation needed for drying, and potentially create a warm, moist environment conducive to bacterial growth. This increases the risk of infection and delays natural cord separation.
Choice D rationale
Cleaning the umbilical cord with water and allowing it to air dry is the most evidence-based practice for routine cord care. Water gently removes any discharge without irritating the skin, and air exposure facilitates the drying process, which is crucial for mummification and eventual detachment. This minimizes the risk of infection and promotes natural healing.
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