The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure.

The infant’s vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute.

Which medication should the nurse hold and inform the health care provider?

Enalapril

Digoxin

Furosemide

Hydralazine

Answer and Explanation

The Correct Answer is B

Choice A rationale
Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. It works by widening blood vessels, which reduces the workload of the heart and helps keep heart failure from getting worse. In the given scenario, there is no specific indication to hold Enalapril based on the infant’s vital signs.
Choice B rationale
Digoxin is a medication that can help the heart beat stronger with a more regular rhythm. However, it is important to monitor the patient’s heart rate when administering Digoxin, as it can lower the heart rate. In this case, the infant’s apical pulse is 88 beats/minute, which is lower than the normal range for an eight-month-old infant (normal range: 100-160 beats/minute). Therefore, the nurse should hold the Digoxin and inform the healthcare provider.
Choice C rationale
Furosemide is a diuretic that helps the kidneys get rid of extra fluid that may build up in the body. It is often used in the treatment of heart failure to relieve symptoms such as fluid retention. In the given scenario, there is no specific indication to hold Furosemide based on the infant’s vital signs.
Choice D rationale
Hydralazine is a medication used to treat high blood pressure. It works by relaxing and widening blood vessels so blood can flow more easily. In the given scenario, there is no specific indication to hold Hydralazine based on the infant’s vital signs.

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Correct Answer is B

Explanation

Choice B rationale
The absence of continuous headaches in the child indicates that the VP shunt is functioning normally. A VP shunt is used to treat hydrocephalus by draining excess cerebrospinal fluid from the brain to the abdomen. If the shunt is functioning properly, it should relieve pressure on the brain and reduce symptoms such as headaches.
Choice A rationale
While growth in height could be a positive sign of overall health and development, it does not specifically indicate that a VP shunt is functioning properly.
Choice C rationale
The presence of an intracranial pressure (ICP) monitoring probe does not indicate whether the shunt is functioning properly. The probe is a device used to measure ICP and does not provide information about the functionality of the shunt.
Choice D rationale
Being afebrile with normal vital signs postoperatively is a positive sign, but it does not specifically indicate that the shunt is functioning properly.

A. Jaundice B. Swelling in the hands or feet C. Ulcers on the legs D. Chest pain

Correct Answer is D

Explanation

Choice D rationale
In a child with sickle cell disease experiencing a sickle cell crisis, chest pain is a serious symptom that should be reported to the healthcare provider immediately. Chest pain could indicate a life-threatening complication known as acute chest syndrome, which is a leading cause of death in people with sickle cell disease.
Choice A rationale
Jaundice is a common symptom in sickle cell disease due to the rapid breakdown of red blood cells, leading to an increase in bilirubin levels. While it should be monitored, it is not typically a symptom that requires immediate medical attention.
Choice B rationale
Swelling in the hands or feet, also known as dactylitis, is a common early symptom of sickle cell disease in children. It is caused by the sickle-shaped red blood cells blocking blood flow to the hands and feet.
Choice C rationale
Leg ulcers are a common complication of sickle cell disease, particularly in adults. They occur less frequently in children and are usually a sign of disease severity.

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Naxlex Comprehensive Predictor Exams

The nurse is monitoring a child with hydrocephalus who received a ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?

Correct Answer is B

Explanation

The nurse is caring for a child with sickle cell disease who is experiencing a sickle cell crisis. Which finding should the nurse report to the healthcare provider immediately?

Correct Answer is D

Explanation

The nurse is caring for a 5-week-old infant who has been experiencing projectile vomiting after feedings. What additional symptom should the nurse anticipate?

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

A nurse is educating parents about essential dietary modifications for their child, who has recently been diagnosed with celiac disease. Which foods should the nurse include in the list of permissible foods for this child?

Which snack choice by a school-aged child with gastroesophageal reflux indicates to the nurse that the child understands the dietary restrictions?

A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?

A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?