The nurse is caring for a child who is diagnosed with severe dehydration and is being treated with intravenous fluids. The nurse notes bilateral crackles on lung auscultation. Which actions will the nurse prioritize?
Call the healthcare provider.
Provide supplemental oxygen.
Stop the infusion.
Encourage oral intake.
The Correct Answer is C
Choice A reason: Calling the healthcare provider is important, but the immediate priority is to stop the infusion to prevent further fluid overload, which is likely causing the bilateral crackles.
Choice B reason: Providing supplemental oxygen can be necessary if the child is showing signs of respiratory distress, but it is not the primary action to address the underlying issue of fluid overload.
Choice C reason: Stopping the infusion is the most critical action to prevent further fluid overload, which is causing the bilateral crackles. This immediate intervention can help prevent worsening pulmonary enema and respiratory complications.
Choice D reason: Encouraging oral intake is not appropriate in this scenario as the child is already receiving intravenous fluids for severe dehydration. Additionally, with signs of fluid overload, further fluid intake should be carefully managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Lack of prenatal care is a significant risk factor for neural tube defects, including myelomeningocele, because it often means the mother did not receive important prenatal vitamins like folic acid, which are crucial for proper neural tube development. Prenatal care provides essential screenings and supplements to support a healthy pregnancy and fatal development. Without it, the risk of congenital anomalies, such as myelomeningocele, increases significantly. Additionally, prenatal care helps in identifying and managing other risk factors and conditions that may affect both maternal and fatal health.
Choice B reason: While active Labor with wounds requires medical attention and may pose risks to both mother and baby, it does not directly correlate with an increased risk of myelomeningocele. Myelomeningocele is a congenital condition related to neural tube development early in pregnancy. The presence of wounds in active Labor may indicate complications such as trauma or infection, but these are not associated with neural tube defects.
Choice C reason: Premature rupture of membranes (PROM) is a condition where the amniotic sac ruptures before Labor begins, potentially leading to preterm birth and infections. While PROM is a concern and requires appropriate medical intervention, it is not directly linked to the development of myelomeningocele. The causes of PROM and neural tube defects like myelomeningocele are different, with PROM often related to issues with the amniotic sac or maternal infections.
Choice D reason: Precipitous Labor, which is an unusually rapid Labor and delivery, can pose risks such as trauma to the birth canal and complications for the newborn, but it is not associated with an increased risk of myelomeningocele. The speed of Labor and delivery is not a contributing factor to neural tube defects. Instead, precipitous Labor is more concerning for potential delivery complications and the need for rapid medical response.
Correct Answer is A
Explanation
Choice A reason: Salmeterol, a long-acting beta-agonist (LABA), is generally not recommended for use during pregnancy due to potential risks to the fetes. It is typically avoided unless absolutely necessary and other safer options are not effective.
Choice B reason: Prednisone is a corticosteroid that can be used during pregnancy when necessary. It is often prescribed for managing severe asthma symptoms, but it should be used under close medical supervision to minimize potential risks.
Choice C reason: Ibuterol is a short-acting beta-agonist (SABA) and is generally considered safe for use during pregnancy. It is commonly used as a rescue inhaler to relieve acute asthma symptoms.
Choice D reason: The text for option D is incomplete and does not provide sufficient information to determine its relevance to the question.
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