The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?

Prepare to hang hypotonic fluids.

Administer oxygen via nasal cannula.

Provide patient education on acute chest syndrome.

Give a dose of morphine sulphate.

Answer and Explanation

The Correct Answer is B

Choice A reason: Preparing to hang hypotonic fluids is not the immediate priority in this situation. While hydration is important for managing sickle cell anaemia, the infant's respiratory distress and low oxygen saturation levels indicate that addressing oxygenation should be the first step. Hypotonic fluids may be considered after stabilizing the patient's breathing and oxygen levels.

Choice B reason: Administering oxygen via nasal cannula is the priority intervention given the infant's symptoms. The infant has increased work of breathing, a fever, coarse crackles upon auscultation, and low oxygen saturation (89%). Providing supplemental oxygen is crucial to improve oxygenation and alleviate respiratory distress. Prompt intervention is necessary to prevent further complications and stabilize the patient's condition.

Choice C reason: Providing patient education on acute chest syndrome is important, but it is not the immediate priority in this emergency situation. Education can be given once the infant's acute symptoms are managed and stabilized. The focus should be on addressing the critical needs first, such as oxygenation and respiratory support.

Choice D reason: Giving a dose of morphine sulphate may help manage pain, but it is not the first priority in this scenario. The infant's respiratory status and oxygenation levels are more critical and require immediate attention. Pain management can be addressed after ensuring the infant's breathing and oxygen levels are stabilized.

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Correct Answer is B

Explanation

Choice A reason: While nausea, tiredness, and sleepiness are common during the first trimester of pregnancy, they are typically not signs of an immediate emergency. This patient does not exhibit any alarming symptoms that would require immediate hospital referral.

Choice B reason: Blurred vision and seeing spots during pregnancy can be symptoms of preeclampsia, a potentially dangerous condition characterized by high blood pressure. Preeclampsia can pose serious health risks to both the mother and the baby and requires immediate medical attention.

Choice C reason: Frequent urination is a common symptom in the later stages of pregnancy due to the pressure the growing baby exerts on the bladder. This symptom alone does not indicate an immediate need for hospital evaluation.

Choice D reason: Having 4 to 5 contractions in an hour at 37 weeks of pregnancy can be a sign of early labor. However, unless the contractions are persistent and intensifying, this may not necessitate an immediate hospital referral. The nurse would likely advise the patient to monitor the contractions and come in if they continue or become stronger.

A. Seek medical attention if the newborn has a fever. B. Watch out for yellowing of the skin or eyes. C. Adhere to the recommended vaccine schedule. D. Administer factor VIII replacement as indicated. E. Provide oral penicillin V potassium to prevent infection.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Seeking medical attention if the newborn has a fever is crucial for children with sickle cell anaemia. Fever can be an early sign of infection, and children with sickle cell anaemia are at a higher risk for infections. Prompt medical evaluation and treatment are necessary to prevent severe complications.

Choice B reason: Watching out for yellowing of the skin or eyes (jaundice) is important because it can indicate homolysis, a common issue in sickle cell anaemia where red blood cells break down rapidly. Identifying jaundice early allows for timely medical intervention to address underlying causes and prevent further complications.

Choice C reason: Adhering to the recommended vaccine schedule is essential for protecting children with sickle cell anaemia from preventable infections. Their immune systems are often compromised, making them more susceptible to infections that vaccines can help prevent.

Choice D reason: Administering factor VIII replacement is not relevant to sickle cell anaemia. Factor VIII replacement is a treatment for haemophilia, a different blood disorder. This intervention is not applicable in the context of sickle cell anaemia education.

Choice E reason: Providing oral penicillin V potassium to prevent infection is a standard recommendation for children with sickle cell anaemia. Daily prophylactic penicillin helps reduce the risk of serious infections, particularly from Streptococcus pneumoniae, which can be life-threatening in these patients.

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The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The clinic nurse is performing phone triage on pregnant patients. Which patient will the nurse refer to the hospital for immediate evaluation?

Correct Answer is B

Explanation

The nurse is teaching parents of a newborn recently diagnosed with sickle cell anaemia. Which interventions will the nurse include in the education? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

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