Exhibits
The nurse is reviewing the prescription and planning the appropriate pain management.
Complete the following sentence by choosing from the lists of options.
For best pain management, the nurse should give... of acetaminophen every 4 hours as scheduled.
3.3 mL
1.9 mL
5.0 mL
0.8 mL
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hepatitis B immunoglobulin. Hepatitis B immunoglobulin (HBIG) is administered to newborns whose mothers are hepatitis B surface antigen (HBsAg) positive to provide passive immunity. Since the client’s hepatitis B status is negative, there is no need for HBIG administration to the newborn.
B. Rubella vaccination. The client is rubella non-immune, meaning they are susceptible to rubella infection, which can cause congenital defects in future pregnancies. The rubella vaccine is a live attenuated virus and is contraindicated during pregnancy but should be administered postpartum before discharge to ensure immunity before the next pregnancy. Breastfeeding is not a contraindication to vaccination.
C. Blood transfusion. The client's hemoglobin (12.5 g/dL) and hematocrit (34%) are within the normal range for postpartum values, indicating that a blood transfusion is not necessary. Blood transfusions are reserved for clients with severe anemia (hemoglobin below 7 g/dL) or significant postpartum hemorrhage.
D. Penicillin G potassium. Group B Streptococcus (GBS) positive status is relevant during labor and delivery, requiring intrapartum antibiotic prophylaxis to prevent neonatal sepsis. Since delivery has already occurred, there is no need for Penicillin G at this time unless there are signs of an active infection in the mother or newborn.
Correct Answer is D
Explanation
A. Determine if the child can administer the insulin. While older children with type 1 diabetes can learn to self-administer insulin, a newly diagnosed 10-year-old may not yet have the skills or confidence to manage injections independently. The primary caregiver should first learn the procedure to ensure proper insulin administration.
B. Ask if the father can help with the injections. While involving another caregiver can be helpful, the mother, as a primary caregiver, needs to learn how to administer insulin. Avoiding the task entirely could compromise the child’s diabetes management, so supporting the mother in overcoming her fear is the priority.
C. Assess the mother's parenting skills. A fear of needles does not indicate poor parenting skills. Many people have needle-related anxiety, and the nurse should focus on providing support and education rather than questioning the mother’s ability to care for her child.
D. Encourage the mother to handle the needles. Helping the mother gradually become comfortable with insulin syringes through guided handling, demonstration, and practice can reduce her fear and build confidence. The nurse can use hands-on teaching techniques, such as allowing the mother to practice with an orange before injecting her child, to ease anxiety and ensure she can perform the procedure effectively.
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