This is a 3-year-old with a history of ventricular septal defect. He was born vaginally at 35 weeks and was in the neonatal intensive care unit (NICU) for 3 weeks due to poor feeding. He lives with his parents and an older sibling, who has no medical conditions. The client is here for a follow-up visit. The nurse educates the parents on post-discharge care for the child.
What should the nurse include in post-discharge care education? Select all that apply.
Keep a pressure dressing on the site for one week
The child may take ibuprofen for pain
Alert the physician if the site bleeds or swells
Give only clear liquids for several days
Avoid any kind of bath or shower
Monitor for fever
Correct Answer : C,F
In post-discharge care education for a 3-year-old with a history of ventricular septal defect, the nurse should include the following:
C. Alert the physician if the site bleeds or swells: This is important because it may indicate complications or issues related to the ventricular septal defect.
F. Monitor for fever: Fever can be a sign of infection or other concerns, so it's important to monitor for any changes in the child's temperature.
The other options are not applicable or advisable for post-discharge care in this context:
A. Keeping a pressure dressing on the site for one week is not typically necessary for ventricular septal defect and may not be appropriate for a 3-year-old.
B. Giving ibuprofen for pain is not relevant in this context, as pain management for ventricular septal defect is not typically managed with ibuprofen.
D. Giving only clear liquids for several days is not indicated for ventricular septal defect or post-discharge care.
E. Avoiding any kind of bath or shower is not a standard practice for post-discharge care for a child with a ventricular septal defect.
The focus should be on monitoring for signs of complications, such as bleeding, swelling, or fever, and seeking medical attention when necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Projectile vomiting in a 5-week-old infant can be indicative of a condition known as pyloric stenosis. Pyloric stenosis is a narrowing of the pylorus, the opening from the stomach to the small intestine. It results in delayed gastric emptying, leading to the forceful, projectile vomiting observed after feedings.
A. An olive-size mass in the epigastric area is a characteristic finding in infants with pyloric stenosis. The hypertrophied pyloric muscle feels like an olive and is often palpable in the upper abdomen.
B. Stool that consists of mucus and blood is not a typical finding associated with pyloric stenosis. This symptom is more suggestive of gastrointestinal issues like infectious colitis or other conditions unrelated to pyloric stenosis.
C. Rebound tenderness in the left lower abdominal quadrant is not a common finding in infants with pyloric stenosis. Rebound tenderness is typically associated with conditions like appendicitis in a different part of the abdomen.
D. Frequent burping accompanied by poor feeding can be a sign of discomfort but is not a specific indicator of pyloric stenosis. Projectile vomiting is a more distinctive symptom associated with this condition.
Correct Answer is D
Explanation
A. Plays "peek-a-boo."
This is a social and cognitive milestone. Infants typically develop social interactions like peek-a-boo around 6-9 months of age. This behavior is normal for a 6-month-old and demonstrates social engagement.
B. Has doubled birth weight.
Infants generally double their birth weight by around 6 months of age. This is a typical growth and developmental milestone, indicating adequate nutrition and growth.
C. Turns head to locate sound.
This is a normal developmental milestone for an infant. By 6 months of age, infants should demonstrate localization of sounds, indicating appropriate auditory and neurological development.
D. Demonstrates startle reflex.
The startle reflex, also known as the Moro reflex, is normal in newborns but typically disappears by 3-6 months of age. If a 6-month-old still exhibits this reflex, it could be a sign of delayed neurological development and might require further evaluation.
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