Patient Data

Exhibits

The nurse is considering appropriate education for the client's new diagnosis.

Choose the most likely option for the information missing from the statement by selecting from the list of options provided. The nurse teaches the parents about decreasing the risk of aspiration when feeding by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A"}

Rationale for Correct Choice

Interrupting feeding if the infant raises their eyebrows: Infants with a submucous cleft palate are at increased risk for aspiration due to abnormal palate structure. Observing subtle cues, such as raising eyebrows or coughing, and pausing the feeding helps prevent formula or saliva from entering the airway.

Rationale for Incorrect Choices

Waiting until the end of each feeding to burp: Delaying burping can increase the risk of aspiration and discomfort, as air swallowed during feeding may cause regurgitation or vomiting in infants with cleft palate.
Placing the infant in a reclining position at 45 degrees: Reclining can worsen the risk of aspiration. The infant should be positioned upright or semi-upright to facilitate safe swallowing and reduce airway compromise.

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Correct Answer is B

Explanation

Rationale:

A. Assess the client's perineal area for signs of a perineal hematoma: While important, there is no indication from the question that suggests a hematoma. This is not the priority.

B. Check the differential, since the WBC is normal for this client: After childbirth, it is normal for WBC levels to increase (often up to 20,000–30,000/mm³) due to the physiological stress of labor. Therefore, a WBC of 15,000/mm³ on postpartum day 1 is expected and not immediately concerning. The nurse should recognize this as normal and can review the differential if needed, but no urgent intervention is required.

C. Assess the client's temperature, heart rate, and respirations every 4 hours: Vital signs monitoring is important, but direct assessment of the perineum takes priority to identify a potential source of infection or hematoma.

D. Notify the healthcare provider (HCP), since this finding is indicative of infection: Notification is appropriate if a source of infection is identified, but initial assessment must occur first to provide accurate information and guide interventions.

Correct Answer is ["10"]

Explanation

Calculation:

Desired dose = 500 mg.

Available concentration = 250 mg / 5 mL

= 50 mg/mL.

Calculate the volume to administer in milliliters (mL).

Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)

= 500 mg / 50 mg/mL

= 10 mL.

View Question and Answer

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Naxlex Comprehensive Predictor Exams

One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell (WBC) count is 15,000/mm3 (15x 10/L). Which action should the nurse take first? Reference Range: White Blood Cell 5,000 to 10,000/mm3 (5 to 10 10/L)]

Correct Answer is B

Explanation

Correct Answer is ["10"]

Explanation

A 4-month-old has been admitted to the pediatric medical unit with respiratory syncytial virus (RSV). The infant demonstrates poor feeding and begins coughing frequently. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

The nurse is caring for a multiparous client who is in labor and observes a fetal heart rate (FHR) that decreases with the peak of a contraction and returns to baseline in 30 seconds. Which action should the nurse implement?

When inspecting the ears of a toddler without the use of an otoscope, which action should the nurse take?

The nurse is assessing a client at 29-weeks gestation. Which assessment method would provide the most accurate determination of fetal position?

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Patient Data Exhibits The nurse is performing an assessment on the toddler. For each assessment finding, click to indicate whether the findings from the assessment should be a concern or not a concern to the nurse. Each row must have only one response option selected.