The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents.
Which information is most important for the nurse to include?

Ensure that the infant’s crib mattress is firm.

Prop the infant with a pillow when in a side-lying position.

Swaddle the infant in a blanket for sleeping.

Place the infant in a prone position whenever possible.

Answer and Explanation

The Correct Answer is A

Choice A rationale

A firm crib mattress is crucial in reducing the risk of Sudden Infant Death Syndrome (SIDS). Soft surfaces can conform to the infant’s face and potentially block their airway, leading to suffocation.

Choice B rationale

Propping the infant with a pillow when in a side-lying position is not recommended as it increases the risk of SIDS. Infants should always be placed on their backs to sleep.

Choice C rationale

Swaddling the infant in a blanket for sleeping is not the most important measure to prevent SIDS. Overheating and loose bedding are risk factors for SIDS23.

Choice D rationale

Placing the infant in a prone position whenever possible is not recommended. Infants should always be placed on their backs to sleep to reduce the risk of SIDS23.

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Correct Answer is D

Explanation

Choice A rationale
Ceasing the use of the nasal cannula would interrupt the client’s oxygen therapy, which could potentially worsen their condition. Therefore, this is not the best course of action.
Choice B rationale
Reducing the flow rate to 1 L/minute may not be appropriate as the client’s oxygen needs may not be met at a lower flow rate. The redness under the chin is likely due to the friction from the cannula tubing, not the flow rate of the oxygen.
Choice C rationale
Applying lubricant to the cannula tubing may not be effective in preventing skin breakdown and could potentially cause additional discomfort or complications for the client.
Choice D rationale
Attaching padding around the cannula tubing can help reduce the friction between the tubing and the skin, which can help prevent skin breakdown. This is the most appropriate action to take in this situation.

A. Observe for bleeding side effects related to heparin therapy. B. Encourage mobilization to prevent pulmonary embolism. C. Assess blood pressure and heart rate at least every 4 hours. D. Measure each calf’s girth to evaluate edema in the affected leg.

Correct Answer is A

Explanation

Choice A rationale

Heparin is an anticoagulant medication that prevents the formation of blood clots. One of the most common and serious side effects of heparin therapy is bleeding. Therefore, it is crucial for the nurse to observe for signs of bleeding, such as bruising, petechiae, hematomas, black tarry stools, hematuria, and changes in mental status. Regular laboratory monitoring of the client’s coagulation status, specifically the activated partial thromboplastin time (aPTT), is also necessary to ensure therapeutic levels of heparin without causing excessive bleeding.

Choice B rationale

While mobilization can help prevent the formation of new clots, it is not the most important intervention for a client who is already on a heparin protocol for DVT. Mobilization can potentially dislodge the existing clot, leading to a life-threatening pulmonary embolism.

Choice C rationale

Although it is important to monitor vital signs in all clients, assessing blood pressure and heart rate every 4 hours is not the most important intervention for a client on a heparin protocol.

Changes in blood pressure and heart rate are not specific to heparin therapy and do not provide direct information about the effectiveness or side effects of the medication.

Choice D rationale

Measuring each calf’s girth can help evaluate the progression of edema in the affected leg, but it is not the most important intervention for a client on a heparin protocol. While it can provide information about the local effects of the DVT, it does not address the systemic anticoagulation effects of heparin therapy.

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The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

Correct Answer is D

Explanation

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

Correct Answer is A

Explanation

The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery. What immediate action should the nurse take?

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A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes. Which behaviors should the nurse prioritize for monitoring?

A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing action?

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents.
Which information is most important for the nurse to include?