The nurse is assisting in planning care for the child.
Which of the following interventions should the nurse plan to include?
Obtain daily weights.
Obtain blood pressure every 8 hours.
Maintain seizure precautions.
Maintain a sodium-restricted diet.
The Correct Answer is C
Choice A rationale
Daily weights are primarily used for fluid balance monitoring, especially in cases like heart failure or renal conditions. It is not a standard intervention unless specifically indicated for the child’s clinical condition.
Choice B rationale
Routine blood pressure checks every 8 hours are not typically necessary for pediatric patients unless there is a concern for hypertension or critical illness. This intervention is not universally applicable.
Choice C rationale
Seizure precautions are crucial for ensuring patient safety in children with a history or risk of seizures. They include measures such as padded side rails, oxygen availability, and maintaining a safe environment.
Choice D rationale
Sodium-restricted diets are not routinely prescribed for children unless there is an underlying condition like kidney or cardiac disease. This intervention does not apply broadly to pediatric care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
HbA1c testing does not measure oxygen-carrying capacity. Instead, that is assessed by the hemoglobin or oxygen saturation levels. HbA1c specifically evaluates glycosylated hemoglobin, indicating average blood glucose levels over time.
Choice B rationale
Testing for urinary ketones is a separate diagnostic test used to detect ketoacidosis, a complication of diabetes. HbA1c does not assess ketones but reflects long-term glycemic control by analyzing glucose bound to hemoglobin.
Choice C rationale
HbA1c does not measure total hemoglobin but rather the percentage of hemoglobin bound to glucose. Therefore, this test provides insight into blood sugar levels rather than the actual quantity of hemoglobin in the blood.
Choice D rationale
The HbA1c test reflects blood sugar control over the past 2-3 months by measuring the proportion of glycosylated hemoglobin. This provides a long-term overview of glucose management, crucial for optimizing treatment in diabetes mellitus.
Correct Answer is A
Explanation
Choice A rationale
Administering oxygen therapy addresses hypoxemia caused by cyanotic episodes and decreased oxygen saturation. Supplemental oxygen improves alveolar oxygenation and enhances oxygen delivery to tissues. Cyanosis during coughing episodes indicates compromised respiratory function due to mucus obstruction, increasing oxygen demand. Normal oxygen saturation for infants is 95%-100%. The immediate priority is stabilizing oxygen levels to prevent respiratory distress and hypoxic injury, ensuring the infant receives adequate oxygenation until further interventions are implemented.
Choice B rationale
Encouraging oral hydration helps alleviate dehydration and thin mucus secretions. The infant’s lack of wet diapers for 8 hours signifies potential dehydration due to vomiting and inadequate feeding. While hydration supports overall respiratory health, it does not directly address the acute hypoxemia observed during cyanotic episodes. Normal urine output for infants is at least 1 mL/kg/hour. Priority action targets the most critical symptoms, rendering hydration a secondary measure after oxygen administration.
Choice C rationale
Placing the infant in an upright position improves ventilation and drainage of mucus secretions, reducing airway obstruction. Upright positioning alleviates the work of breathing by optimizing lung expansion. While beneficial, positioning alone cannot resolve hypoxemia during cyanosis or acutely improve oxygen saturation. Infants with significant respiratory distress require interventions like oxygen therapy to stabilize life-threatening symptoms prior to supportive measures such as positioning.
Choice D rationale
Preparing for emergency intubation ensures airway patency during severe respiratory compromise. Intubation may become necessary if hypoxemia persists despite oxygen therapy or if mucus obstruction worsens. However, immediate intubation bypasses less invasive initial measures. Oxygen therapy is prioritized to stabilize oxygen levels, allowing reassessment of respiratory status before advancing to more aggressive interventions.
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