Nurses must be alert for increased fluid requirements when a child has:

Mechanical ventilation

Increased intracranial pressure (ICP)

Congestive heart failure

Fever

Answer and Explanation

The Correct Answer is D

Choice A reason: Mechanical ventilation does not necessarily increase the fluid requirements of a child. Mechanical ventilation is a method of providing artificial breathing support to a child who has respiratory failure or insufficiency. Mechanical ventilation may affect the fluid balance of a child by altering the insensible losses, the renal function, or the hemodynamics. However, the net effect may vary depending on the type, mode, and settings of the ventilator, as well as the underlying condition of the child. Therefore, the fluid requirements of a child on mechanical ventilation should be individualized and monitored closely¹.

Choice B reason: Increased intracranial pressure (ICP) does not increase the fluid requirements of a child. Increased ICP is a condition in which the pressure inside the skull is higher than normal, due to various causes such as head injury, brain tumor, infection, or hydrocephalus. Increased ICP may affect the fluid balance of a child by impairing the cerebral blood flow, the cerebrospinal fluid drainage, or the hypothalamic-pituitary axis. However, the net effect may vary depending on the severity, duration, and cause of the increased ICP, as well as the presence of other complications such as cerebral edema or diabetes insipidus. Therefore, the fluid requirements of a child with increased ICP should be individualized and monitored closely².

Choice C reason: Congestive heart failure does not increase the fluid requirements of a child. Congestive heart failure is a condition in which the heart is unable to pump enough blood to meet the body's needs, due to various causes such as congenital heart defects, cardiomyopathy, or infection. Congestive heart failure may affect the fluid balance of a child by causing fluid retention, edema, or pulmonary congestion. However, the net effect may vary depending on the type, severity, and stage of the heart failure, as well as the presence of other complications such as renal failure or liver failure. Therefore, the fluid requirements of a child with congestive heart failure should be individualized and monitored closely³.

Choice D reason: Fever increases the fluid requirements of a child. Fever is a condition in which the body temperature is higher than normal, due to various causes such as infection, inflammation, or immunization. Fever increases the fluid requirements of a child by increasing the metabolic rate, the insensible losses, and the urine output. The amount of fluid loss due to fever depends on the degree and duration of the fever, as well as the ambient temperature and humidity. A general rule of thumb is that for every degree Celsius increase in body temperature, the fluid requirements increase by 10%⁴. Therefore, the fluid requirements of a child with fever should be adjusted and monitored closely.

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Correct Answer is A

Explanation

Choice A reason: Encouraging and helping mother to breastfeed is a supportive and beneficial nursing intervention for a mother who has given birth to an infant with a cleft palate. Breastfeeding provides optimal nutrition, immunity, and bonding for the infant, and may also help prevent infections and promote healing of the cleft. Breastfeeding may be possible for some infants with cleft palate, especially if the cleft is mild or only affects the soft palate. The nurse should assist the mother with positioning, latching, and using devices such as a nipple shield, a breast pump, or a supplemental nursing system. The nurse should also monitor the infant's weight gain, hydration, and output, and provide emotional support and education to the mother.

Choice B reason: Teaching mother to feed breast milk by gavage is not a necessary or desirable nursing intervention for a mother who has given birth to an infant with a cleft palate. Gavage feeding is a method of providing nutrition through a tube that is inserted through the nose or mouth into the stomach. It is usually used for infants who have severe feeding difficulties or other medical conditions that require tube feeding. However, most infants with cleft palate can be fed orally with proper techniques and equipment, and do not need gavage feeding. Gavage feeding may have complications such as infection, irritation, displacement, or obstruction of the tube. It may also interfere with the infant's oral development and bonding with the mother.

Choice C reason: Giving medication to suppress lactation is not a helpful or respectful nursing intervention for a mother who has given birth to an infant with a cleft palate. Medication to suppress lactation is a drug that inhibits the production of breast milk. It is usually used for mothers who choose not to breastfeed or who have medical contraindications to breastfeeding. However, a cleft palate is not a contraindication to breastfeeding, and the mother may still want to breastfeed or express breast milk for her infant. Giving medication to suppress lactation may cause side effects such as nausea, headache, or depression. It may also deprive the infant of the benefits of breast milk, and the mother of the choice and satisfaction of breastfeeding.

Choice D reason: Providing mother with the appropriate formula for the patient is not a sufficient or comprehensive nursing intervention for a mother who has given birth to an infant with a cleft palate. Formula is an artificial substitute for breast milk that provides nutrition for infants who cannot or do not breastfeed. Formula may be used for infants with cleft palate, especially if breastfeeding is not possible or adequate. However, formula does not provide the same immunity, protection, and bonding as breast milk. Providing formula alone does not address the mother's needs, preferences, or feelings about feeding her infant. The nurse should also offer other options, such as expressing breast milk, using a special bottle or cup, or combining breastfeeding and formula feeding. The nurse should also teach the mother how to prepare, store, and administer the formula safely and hygienically.

A. Cardiac arrhythmia B. Decreased cardiac output C. Increased stroke volume D. Cyanosis

Correct Answer is B

Explanation

Choice A reason: Cardiac arrhythmia is an abnormal heart rhythm that can affect the heart's ability to pump blood. However, it is not a direct consequence of a ventricular septal defect (VSD), which is a hole in the wall between the lower chambers of the heart¹.

Choice B reason: Decreased cardiac output is the amount of blood pumped by the heart per minute. It can be reduced by a VSD, as the blood can flow back from the left ventricle to the right ventricle through the hole, instead of being pumped to the body. This can cause the infant to have cool extremities, thready pulses, and low urine output, as the tissues are not receiving enough oxygen and nutrients².

Choice C reason: Increased stroke volume is the amount of blood pumped by the heart per beat. It can be increased by a VSD, as the left ventricle has to work harder to compensate for the blood loss through the hole. However, this does not explain the infant's symptoms, as the stroke volume may not be enough to maintain a normal cardiac output².

Choice D reason: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. It can be caused by a VSD, as the oxygen-rich blood from the left ventricle can mix with the oxygen-poor blood from the right ventricle through the hole, and then be pumped to the body. However, this is more likely to occur in large VSDs or in infants with other heart defects that cause right-to-left shunting of blood³.

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Nurses must be alert for increased fluid requirements when a child has:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother who intended to breastfeed has given birth to an infant with a cleft palate. Which nursing interventions should be included in the plan of care?

Correct Answer is A

Explanation

A six-month-old infant is hospitalized for repair of a ventricular septal defect. As you are doing his physical exam, you note that the infant's extremities are cool, he has thready pulses, and his urine output is diminished. These clinical findings are suggestive of which of the following?

Correct Answer is B

Explanation

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