Exhibits

Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate. Each row must have one option selected.

Ask the healthcare provider to prescribe a nonsteroidal antiinflammatory drug.

Have one of the parents hold the baby.

Perform guided imagery.

Consult a child life specialist.

Encourage the baby's mother to breastfeed the baby.

Wait 1 hour, reassess, and give medication if the FLACC score remains elevated.

Request a prescription for an opioid.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"},"G":{"answers":"A"}}

Ask the healthcare provider to prescribe a nonsteroidal anti-inflammatory drug (NSAID)
NSAIDs such as ibuprofen are commonly used for postoperative pain relief in infants. They provide anti-inflammatory effects and pain control without the risk of respiratory depression seen with opioids. Given the infant’s surgical status, an NSAID can be an effective pain management option when prescribed appropriately.
Have one of the parents hold the baby: Parental presence and skin-to-skin contact are effective non-pharmacologic pain management strategies for infants. Holding and gentle rocking can provide comfort, reduce stress, and help lower the infant’s FLACC score by promoting relaxation.
Perform guided imagery: Guided imagery requires cognitive maturity, which a 4-month-old infant lacks. This technique is more appropriate for older children who can understand and visualize calming scenes. For infants, tactile and auditory comfort measures (such as holding and swaddling) are more effective.
Consult a child life specialist: A child life specialist can assist in non-pharmacologic pain management strategies, such as age-appropriate distraction techniques, comfort positioning, and soothing interventions. While the infant may not engage in interactive play, the specialist can help guide parents in comforting their baby.
Encourage the baby's mother to breastfeed the baby: The infant is NPO (nothing by mouth) postoperatively, meaning breastfeeding is contraindicated at this time. Providing oral intake against medical orders could lead to complications, especially after fundoplication surgery, which affects gastric emptying.
Wait 1 hour, reassess, and give medication if the FLACC score remains elevated: Delaying pain relief for an infant experiencing postoperative pain is not appropriate. Infants cannot verbalize pain, and an elevated FLACC score indicates discomfort. Instead of waiting, the nurse should take immediate action by implementing comfort measures and/or requesting appropriate pain medication.
Request a prescription for an opioid: If the infant's pain is moderate to severe, an opioid (such as morphine) may be needed for adequate pain relief. Opioids are used cautiously in infants due to the risk of respiratory depression, but they are appropriate for postoperative pain control when NSAIDs alone are insufficient.

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Correct Answer is ["A","C","D"]

Explanation

A. Turn off the suction on the nasogastric tube. The client has been experiencing continuous nasogastric (NG) suction, which can lead to fluid and electrolyte imbalances. The client's low blood pressure (86/64 mm Hg), leg cramping, and fatigue suggest volume depletion and possible electrolyte loss. Discontinuing NG suction will help prevent further fluid loss and electrolyte depletion.
B. Bolus calcium. The client’s calcium levels (9.2 mg/dL and 9.1 mg/dL) are within normal range (8.5–10.2 mg/dL). Since there is no indication of hypocalcemia, a calcium bolus is not necessary.
C. Increase the intravenous fluid rate. The client’s low blood pressure, tachycardia (96 bpm), and signs of fatigue suggest hypovolemia, likely due to fluid losses from NG suction and inadequate IV fluid replacement. Increasing IV fluid rate can help restore circulatory volume and improve perfusion.
D. Add potassium to the intravenous fluids. The client’s potassium level has dropped from 3.8 mEq/L to 3.5 mEq/L, which is at the lower limit of normal (3.5–5.0 mEq/L). Prolonged NG suctioning can cause hypokalemia, leading to muscle cramps, weakness, and fatigue. Adding potassium to IV fluids can prevent further decline and correct the deficiency.
E. Administer a diuretic. The client is already hypovolemic due to NG losses, as evidenced by low blood pressure and tachycardia. A diuretic would further exacerbate volume depletion, making it an inappropriate intervention.
F. Flush the central line with 3% sodium chloride. The client's sodium levels are normal (139–142 mEq/L), so a hypertonic saline flush (3% NaCl) is not needed. This type of fluid is typically used for severe hyponatremia, which is not present in this case.
G. Decrease the percentage of sodium in the intravenous fluids. The client is receiving Dextrose 5% in 0.9% sodium chloride, which provides isotonic hydration. Since the sodium level is within normal limits and the client is hypovolemic, reducing sodium concentration in IV fluids is not necessary.

A. Heat loss. B. Fluid balance. C. Bleeding tendencies. D. Hypoglycemia.

Correct Answer is A

Explanation

A. Heat loss. Newborns are highly susceptible to heat loss due to their large surface area relative to body weight and limited ability to generate heat. Cold stress can lead to hypoglycemia, respiratory distress, and metabolic acidosis. To prevent this, the nurse should dry the newborn thoroughly, provide skin-to-skin contact, and use a radiant warmer or warm blankets immediately after birth.
B. Fluid balance. While newborns require close monitoring of fluid balance, they are born with sufficient fluid stores. Dehydration is not an immediate concern within the first few minutes of life. Initial interventions focus on thermoregulation and establishing respiration.
C. Bleeding tendencies. Newborns have low vitamin K levels, which increase the risk of bleeding. However, vitamin K prophylaxis is given within the first hour after birth and is not the immediate priority over establishing adequate oxygenation and thermoregulation.
D. Hypoglycemia. Hypoglycemia is a concern, especially in infants of diabetic mothers or those with low birth weight. However, preventing heat loss is a higher priority, as cold stress can contribute to hypoglycemia. Once thermoregulation is established, glucose monitoring can be performed as needed.

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Exhibits Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate. Each row must have one option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D"]

Explanation

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. Which priority issue should the nurse address to ensure the newborn's survival?

Correct Answer is A

Explanation

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Exhibits

Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate. Each row must have one option selected.