The nurse who is working on a pediatric unit receives a shift report for four neonates with congenital heart defects. The neonate with which report requires the most immediate intervention?

Ventricular septal defect (VSD) has audible murmurs.

Patent ductus arteriosus is fatigued after feeding

Coarctation of aorta has an elevated blood pressure in the upper extremity.

Tetralogy of Fallot (TOF) with hypercyanotic (Tet) spells is crying.

Answer and Explanation

The Correct Answer is D

Choice A rationale

An audible murmur in a neonate with a ventricular septal defect (VSD) is a common finding and does not typically require immediate intervention. While it indicates a cardiac anomaly, it is not an emergency.

Choice B rationale

Fatigue after feedings in a neonate with patent ductus arteriosus (PDA) is a sign of increased cardiac workload, but it does not indicate an immediate life-threatening situation. It requires monitoring but not urgent intervention.

Choice C rationale

Elevated blood pressure in the upper extremity in a neonate with coarctation of the aorta is a concerning finding that indicates a narrowing of the aorta. While it requires prompt evaluation and management, it may not be as immediately critical as a hypercyanotic spell.

Choice D rationale

A neonate with Tetralogy of Fallot (TOF) experiencing hypercyanotic (Tet) spells and crying indicates a severe decrease in oxygenation and is an emergency. This condition requires immediate intervention to improve oxygenation and prevent complications such as brain damage or death. .

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Correct Answer is B

Explanation

Choice A rationale

Rooting is a reflex that helps a baby find and latch onto the breast or bottle for feeding. While the rooting reflex may diminish as the baby grows, it is not the primary indicator for introducing solid foods. Other developmental milestones are more relevant for this transition.

Choice B rationale

When a baby starts opening their mouth in response to the sight or smell of food, it indicates a readiness to try solid foods. This behavior shows that the baby is interested in and capable of learning to eat from a spoon, which is a key step in the introduction of solids.

Choice C rationale

Awakening once for nighttime feedings is common for infants and does not necessarily indicate readiness for solid foods. Nighttime awakenings can occur for various reasons, including hunger, but other developmental signs should be considered for introducing solids.

Choice D rationale

Giving up a bottle for a cup is a milestone that typically occurs later in infancy or toddlerhood. It is not directly related to the introduction of solid foods, which generally begins around 4 to 6 months of age based on the child's developmental readiness and interest in food.

A. Increasing intake of protein might improve these values. B. Plasma volume increases, making the blood count appear low. C. It might be necessary to take an iron supplement twice daily. D. Almost all women at 28-weeks gestation have anemia.

Correct Answer is B

Explanation

Choice A rationale

While increasing protein intake is beneficial for overall health and pregnancy, it is not the primary factor that affects hemoglobin and hematocrit levels. These levels are more directly influenced by iron intake and the physiological changes during pregnancy. Protein intake is important for fetal growth and development, but it does not significantly alter the concentration of hemoglobin or hematocrit in the blood.

Choice B rationale

During pregnancy, plasma volume increases by approximately 50%, leading to hemodilution. This means that even though the total number of red blood cells increases, the concentration of hemoglobin and hematocrit appears lower due to the larger volume of plasma. This physiological change helps meet the increased oxygen demands of both the mother and the growing fetus and is a normal part of pregnancy.

Choice C rationale

Taking an iron supplement can help improve hemoglobin and hematocrit levels, especially if a pregnant woman has iron-deficiency anemia. Iron is essential for the production of hemoglobin, which carries oxygen in the blood. However, not all pregnant women with lower hemoglobin and hematocrit levels need to take iron supplements, as these values can be within the expected range for pregnancy. The decision to supplement should be based on individual assessment by a healthcare provider.

Choice D rationale

Not all women at 28 weeks gestation have anemia. While it is common for hemoglobin and hematocrit levels to be lower during pregnancy due to increased plasma volume, it does not mean that all pregnant women are anemic. Anemia is diagnosed based on specific thresholds for hemoglobin and hematocrit levels, and the values mentioned (hemoglobin 10.7 g/dL and hematocrit 32%) are borderline and may not necessarily indicate anemia.

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The nurse who is working on a pediatric unit receives a shift report for four neonates with congenital heart defects. The neonate with which report requires the most immediate intervention?

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Naxlex Comprehensive Predictor Exams

The mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant.The mother states, "My mother says I should put rice cereal in the baby's bottle now.”. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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