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 D

Explanation

Choice A reason: Saying two-word sentences is an expected developmental milestone for an 18-month-old child. At this age, children should begin combining two words to form simple sentences, such as "more juice" or "mama go." This indicates normal language development.

Choice B reason: Using a pincer grasp to eat Cheerio’s is a typical fine motor skill for an 18-month-old child. The ability to pick up small objects between the thumb and forefinger demonstrates proper development of fine motor skills and hand-eye coordination.

Choice C reason: Removing shoes and socks is a common developmental milestone for an 18-month-old child. This task shows growing independence and the ability to perform basic self-care activities, which is a sign of normal development.

Choice D reason: Preferring to use the right hand may suggest a developmental delay because children typically do not show a strong hand preference (left or right) until around the age of 2 to 3 years. Early hand dominance can be a sign of an underlying issue, such as asymmetry in muscle strength or neurological development. It is important to assess further if a child shows a strong preference for one hand at this early age.

A. Facilitate an early discharge. B. Discontinue oxycodone administration. C. Restrict visitor time. D. Provide breast pump.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Facilitating an early discharge is not appropriate in this case. Patients with PPROM require careful monitoring and management to prevent infections and other complications.

Choice B reason: Discontinuing oxycodone administration may be necessary to prevent potential adverse effects on both the patient and the baby, especially considering the patient's recent delivery and current condition.

Choice C reason: Restricting visitor time can help reduce the risk of infection, especially for a patient with PPROM and a newborn who may have a compromised immune system.

Choice D reason: Providing a breast pump is important to help the mother establish and maintain lactation, especially if the baby is premature and may have difficulty breastfeeding directly.

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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 nurse is assessing an 18-month-old patient at a well-child visit. What findings would suggest a developmental delay?

Correct Answer is D

Explanation

The nurse is caring for a G4P1, 31 weeks and 2 days gestation, 41-year-old patient, with premature prolonged rupture of membranes (PPROM) 7 hours after delivery. Which interventions will the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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