The nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this infant? (Select All that Apply.)
Maintain a thermoneutral environment
Accurately measure all intake and output
Provide for several periods of uninterrupted rest
Incentive spirometer 10 times every hour
Encourage periods of bonding
Correct Answer : A,B,C,E
A. Maintain a thermoneutral environment: Helps prevent temperature fluctuations that can stress the heart post-surgery.
B. Accurately measure all intake and output: Ensures fluid balance is carefully monitored to prevent fluid overload or dehydration.
C. Provide for several periods of uninterrupted rest: Reduces metabolic demand, aiding in recovery and healing.
D. Incentive spirometer 10 times every hour: Inappropriate for infants following cardiac surgery, as they are unable to effectively use an incentive spirometer.
E. Encourage periods of bonding: Supports emotional well-being and aids in the infant's overall recovery and development.
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Related Questions
Correct Answer is B
Explanation
A. Provide education on oral contraceptives. This is not a priority for treating acute PID, though education on preventing sexually transmitted infections (STIs) that can lead to PID is important.
B. Removal of intrauterine device prior to treatment. This is a priority intervention because an intrauterine device (IUD) can be a source of infection and inflammation, exacerbating pelvic inflammatory disease (PID). Removing it can help reduce infection risk and facilitate treatment.
C. Institute contact precautions. PID is typically not spread by casual contact, so standard precautions are sufficient.
D. Administer acyclovir as ordered. Acyclovir is used to treat viral infections like herpes and is not relevant for bacterial infections like PID, which is usually treated with antibiotics.
Correct Answer is D
Explanation
A. Playing on the backyard swings and running around outside are exercises our child will really enjoy. Encouraging physical activity is beneficial as it helps with lung function and overall health.
B. Three to four times a day we will perform chest therapy and postural drainage on our child. This is correct and necessary to help clear mucus from the lungs.
C. A high protein, high-calorie diet may need to be supplemented with a high-calorie formula. This is important for meeting the nutritional needs of children with cystic fibrosis due to their higher caloric requirements.
D. Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements. This is incorrect; children with cystic fibrosis typically need pancreatic enzyme supplements with every meal and snack to aid digestion, regardless of appetite or bowel regularity.
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