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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.
Correct Answer is B
Explanation
A. Oversupply of milk. This can lead to milk stasis and blockage, which can increase the risk of mastitis.
B. Gradual weaning of breastfeeding. Gradual weaning typically helps reduce the risk of mastitis because it allows the milk supply to decrease slowly and naturally without engorgement or blockage.
C. Infrequent, inconsistent feedings. This can lead to milk stasis and is a common cause of mastitis.
D. Cracks or fissures of the nipples. These can provide an entry point for bacteria, leading to infection and mastitis.
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