The parents of a child with acute lymphoblastic leukemia (ALL) are learning to care for their child at home. Which statement made by the parents should the nurse recognize as correct monitoring for early signs of an infection in the child?
Reassess axillary temperature if it is higher than 99.7° F (37.6° C).
Verify if the child has a fever by checking a rectal temperature.
Notify for a temporal temperature greater than 100° F (37.8° C).
Check temperature twice a day with an aural thermometer.
The Correct Answer is C
Choice A reason: Reassessing axillary temperature if it is higher than 99.7° F (37.6° C) is not a correct monitoring for early signs of an infection in the child. Axillary temperature is not the most accurate method of measuring body temperature, especially in children. It can be affected by factors such as clothing, sweating, and room temperature. Axillary temperature is usually lower than the core body temperature by about 1° F (0.6° C). Therefore, a child with an axillary temperature higher than 99.7° F (37.6° C) may already have a significant fever and should be evaluated by a health care provider.
Choice B reason: Verifying if the child has a fever by checking a rectal temperature is not a correct monitoring for early signs of an infection in the child. Rectal temperature is the most accurate method of measuring body temperature, but it is also the most invasive and uncomfortable. It can cause irritation, bleeding, or injury to the rectum, especially in children with low platelet counts or bleeding disorders. Rectal temperature is also not recommended for children with acute lymphoblastic leukemia, as it can increase the risk of introducing bacteria or fungi into the bloodstream.
Choice C reason: Notifying for a temporal temperature greater than 100° F (37.8° C) is a correct monitoring for early signs of an infection in the child. Temporal temperature is a noninvasive and convenient method of measuring body temperature, using an infrared scanner that detects the heat emitted by the temporal artery on the forehead. Temporal temperature is comparable to the core body temperature and can reflect changes in body temperature quickly. A child with acute lymphoblastic leukemia who has a temporal temperature greater than 100° F (37.8° C) may have an infection and should be reported to the health care provider immediately.
Choice D reason: Checking temperature twice a day with an aural thermometer is not a correct monitoring for early signs of an infection in the child. Aural temperature is a noninvasive and easy method of measuring body temperature, using an infrared sensor that detects the heat emitted by the tympanic membrane in the ear. However, aural temperature can be inaccurate or unreliable, as it can be affected by factors such as earwax, ear infections, ear canal shape, and ambient noise. A child with acute lymphoblastic leukemia who has a fever may not be detected by an aural thermometer, and may miss the opportunity for early intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Obtaining a 12-lead electrocardiogram is not the first intervention that the nurse should implement. An electrocardiogram is a test that measures the electrical activity of the heart and can detect abnormalities in the heart rhythm or structure. However, it is not a priority for an infant who has already had surgical correction for TOF and is not showing signs of distress.
Choice B reason: Stimulating the infant to cry to produce cyanosis is not an intervention that the nurse should implement at all. Cyanosis is a bluish discoloration of the skin due to low oxygen levels in the blood. It is a common symptom of TOF and can be triggered by crying or other stressors. However, it is not a desirable outcome and can cause harm to the infant. The nurse should avoid provoking cyanosis and instead provide comfort and oxygen to the infant.
Choice C reason: Auscultating heart and lungs while the infant is held is the first intervention that the nurse should implement. This is a simple and noninvasive way to assess the infant's respiratory and cardiac status. The nurse can listen for any abnormal sounds, such as crackles, wheezes, or murmurs, that may indicate a problem. The nurse can also monitor the infant's heart rate and oxygen saturation. Holding the infant can provide comfort and security to the infant and the mother.
Choice D reason: Evaluating the infant for failure to thrive (FTT) is not the first intervention that the nurse should implement. FTT is a condition where an infant does not grow or gain weight as expected. It can be caused by various factors, such as inadequate nutrition, chronic illness, or psychosocial issues. However, the infant in this scenario is not showing signs of FTT, as his growth is in the expected range. The nurse should focus on the infant's current symptoms and needs.
Correct Answer is B
Explanation
Choice A reason: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat heart failure in infants. It lowers blood pressure and reduces the workload of the heart. Enalapril is not contraindicated in this scenario and does not need to be withheld.
Choice B reason: Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias in infants. It increases the contractility of the heart and slows down the heart rate. Digoxin has a narrow therapeutic range and can cause toxicity if the dose is too high or the infant is dehydrated. Digoxin should be withheld if the infant's apical pulse is less than 90 beats/minute, which is the case in this scenario. The nurse should notify the health care provider and monitor the infant for signs of digoxin toxicity, such as nausea, vomiting, bradycardia, and visual disturbances.
Choice C reason: Hydralazine is a vasodilator that is used to treat hypertension and heart failure in infants. It lowers blood pressure and reduces the afterload of the heart. Hydralazine is not contraindicated in this scenario and does not need to be withheld.
Choice D reason: Furosemide is a loop diuretic that is used to treat fluid overload and edema in infants with heart failure. It lowers blood pressure and reduces the preload of the heart. Furosemide is not contraindicated in this scenario and does not need to be withheld
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