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Exhibits

The nurse is reviewing the assessment data.

Which are the 3 most likely reasons that the infant is crying?

Hunger

Opioid withdrawal

Hemorrhage

Separation anxiety

Pain

Hypovolemia

Hypoxia

Answer and Explanation

Correct Answer : A,E,F

A.   Hunger – The infant is NPO postoperatively but is accustomed to regular feedings. Hunger-related distress is common in infants after surgery, especially when oral intake is restricted. Since the infant has a history of GERD and fundoplication surgery, feedings are likely delayed to prevent complications, contributing to crying.
B.   Opioid withdrawal – There is no indication that the infant has been on chronic opioid therapy before surgery. Opioid withdrawal symptoms typically occur in infants exposed to opioids for prolonged periods (e.g., neonatal abstinence syndrome), which is not relevant in this case.
C.   Hemorrhage – The surgical dressing is clean and dry, meaning there are no visible signs of bleeding at the incision site. If significant internal bleeding were occurring, the infant would likely show signs of pallor, tachycardia, and hypotension, which are not present.
D.   Separation anxiety – Separation anxiety typically develops around 6–9 months of age, when infants become more aware of their caregivers' presence. At 4 months, infants can recognize caregivers but do not yet exhibit true separation distress, making this an unlikely reason for crying.
E.   Pain – Postoperative pain is a common cause of crying in infants after surgery. Signs of pain in nonverbal infants include crying, facial grimacing, irritability, and body tension. Since the infant has just undergone fundoplication surgery, pain is a likely contributing factor.
F.   Hypovolemia – The infant is receiving IV fluids (Dextrose 5% with sodium chloride 0.45%), but fluid deficits can still occur postoperatively due to preoperative fasting, surgical fluid losses, or inadequate replacement. Hypovolemia can cause discomfort, irritability, tachycardia, and crying.
G.   Hypoxia – The infant is described as pink and well-perfused with clear breath sounds, which rules out respiratory distress as a likely cause of crying. If hypoxia were present, signs such as cyanosis, increased work of breathing, or abnormal breath sounds would be expected.

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

Explanation

A. Blood type: While important for transfusions, blood type is not relevant to assessing pain or determining appropriate pain management strategies. Pain assessment focuses on physiological and behavioral cues, not blood compatibility.
B. Parents’ religious affiliation: Religious beliefs may influence pain management preferences (e.g., preference for non-pharmacologic methods), but this is not a priority assessment before implementing pain management strategies. The immediate focus should be on assessing the infant’s pain level and physiological status.
C. Blood pressure: Pain can cause increased sympathetic nervous system activity, leading to elevated blood pressure. Monitoring blood pressure helps assess the severity of pain and guides appropriate pain management interventions.
D. Level of consciousness: Infants in significant pain may become restless, irritable, or inconsolable, while excessive sedation from pain medications can cause decreased responsiveness. Assessing level of consciousness helps ensure that pain relief measures do not cause over-sedation or respiratory depression.
E. Hearing acuity: Hearing assessment is not relevant for pain management in a 4-month-old infant. Pain assessment in infants focuses on physiological signs, crying, and behavioral responses, rather than auditory abilities.
F. Heart rate: Pain can lead to tachycardia due to sympathetic nervous system activation. Monitoring heart rate helps assess pain intensity and evaluate the effectiveness of pain relief interventions.
G. Deep tendon reflexes: Reflex testing is used for neurological assessment but is not relevant to pain management. Reflexes do not provide direct information about pain intensity or response to treatment.

A. 3.3 mL B. 1.9 mL C. 5.0 mL D. 0.8 mL

Correct Answer is A

Explanation

A. 3.3mL: The correct dose for infants is 10–15 mg/kg every 4–6 hours. If the infant weighs 7 kg, the correct dose is:Minimum dose: 10 mg × 7 kg = 70 mg. Maximum dose: 15 mg × 7 kg = 105 mg. Since the standard concentration is 160 mg/5 mL, the correct volume for 105 mg is 3.3 mL, making it the most appropriate dose.
B. 1.9 mL: This provides only about 61 mg of acetaminophen, which is below the recommended 10 mg/kg minimum dose, making it potentially ineffective.
C. 5.0 mL: This equates to 160 mg of acetaminophen, which exceeds the safe dose range for most infants, increasing the risk of liver toxicity.
D. 0.8 mL: This would provide only about 26 mg of acetaminophen, which is severely underdosed and unlikely to provide adequate pain relief.

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Exhibits The nurse is reviewing the assessment data. Which are the 3 most likely reasons that the infant is crying?

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Naxlex Comprehensive Predictor Exams

Exhibits Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.

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

Explanation

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Correct Answer is A

Explanation

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Exhibits

The nurse is reviewing the assessment data.

Which are the 3 most likely reasons that the infant is crying?