The practical nurse (PN) is planning care for a child with heart failure. Which intervention should the PN give the greatest priority?
Monitor therapeutic level of phenytoin.
Increase fluid intake.
Cluster care to conserve the child's energy.
Restrict intake of foods high in sugar.
The Correct Answer is C
For a child with heart failure, the greatest priority for the practical nurse (PN) is to conserve the child's energy. Clustered care activities and rest periods will help to conserve the child's energy and minimize the workload on the heart.
Monitoring therapeutic levels of phenytoin (A) is not relevant to the care of a child with heart failure. Increasing fluid intake (B) is not a priority intervention for a child with heart failure, as excessive fluid intake can worsen heart failure. Restricting intake of foods high in sugar (D) may be necessary for a child with heart failure, but it is not the greatest priority for the PN to address.
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Correct Answer is B
Explanation
The infant's symptoms are consistent with postoperative pain, which can be expected following a surgical procedure like pyloromyotomy. The PN should administer the prescribed analgesic medication to relieve the infant's discomfort and pain. It is crucial to manage pain appropriately in infants to promote healing, improve feeding tolerance, and prevent complications.
Option A is not appropriate as the infant's symptoms are not indicative of hypoglycemia.
Option C is not appropriate as the infant's symptoms do not indicate hypothermia.
Option D is not appropriate as the infant's symptoms do not indicate dehydration.
Correct Answer is B
Explanation
The greatest priority for the practical nurse to monitor during the administration of epidural anesthesia is maternal blood pressure (BP). Epidural anesthesia can cause maternal hypotension due to vasodilation and decreased venous return, which can result in decreased fetal perfusion and oxygenation. Therefore, it is important for the practical nurse to monitor maternal BP frequently and promptly report any significant changes to the healthcare provider. Options A, C, and D are also important assessments, but they are not the priority in this scenario.
Therefore, options A, C, and D are not answers because they are not the priority assessment during the administration of epidural anesthesia.
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