A nurse is assessing an infant who has acute otitis media. Which of the following findings should the nurse expect? (Select all that apply.)
Enlarged subclavicular lymph node
Fever
Crying
Increased appetite
Restlessness
Correct Answer : B,C,E
Choice A Reason:
Enlarged subclavicular lymph node (A) is not a typical finding associated with acute otitis media. Enlarged lymph nodes in the neck area (cervical lymph nodes) might be observed due to the nearby infection, but the subclavicular lymph nodes are located below the clavicle and are not typically associated with ear infections.
Choice B Reason:
Fever: Infants with acute otitis media often present with a fever. Elevated body temperature is a common symptom of an infection, including ear infections.
Choice C Reason:
Crying: Ear pain is a common symptom of acute otitis media. Infants may express discomfort or pain by crying, especially when lying down due to increased pressure in the middle ear.
Choice D Reason:
Increased appetite is also not a common finding in acute otitis media. Generally, a decrease in appetite might occur due to feeling unwell or discomfort, but increased appetite is not a typical symptom of this condition.
Choice E Reason:
Restlessness: Due to discomfort or pain caused by the ear infection, infants with acute otitis media might exhibit restlessness or irritability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason
Pulse rate 98/min: A pulse rate of 98 beats per minute is within the expected range for a 2-year-old child (normal range: 70-110 bpm). This finding is generally considered normal for this age and may not require immediate reporting.
Choice B Reason:
Temperature 37.2° C (99° F): A temperature of 37.2°C (99°F) is slightly elevated but is within the range of low-grade fever in children. However, at a well-child visit, this temperature might not be immediately alarming, especially if the child doesn't exhibit other signs of illness.
Choice C Reason:
Blood pressure 118/74 mm Hg:This reading is higher than the normal range for a 2-year-old child. High blood pressure in a young child should be evaluated further to determine the cause and need for intervention.
Choice D Reason:
Respiratory rate 26/min: The normal respiratory rate for a 2-year-old child typically ranges from 20 to 30 breaths per minute. A respiratory rate of 26 breaths per minute is within this range and may not warrant immediate concern.
Correct Answer is C
Explanation
Choice A Reason:
Placing the infant in a prone position might not be suitable for an infant with heart failure. Typically, an upright or semi-upright position can help reduce the workload on the heart by improving respiratory function and aiding in cardiac output.
Choice B Reason:
Repeating a digoxin dosage if the infant vomits within 1 hour of administration isn't recommended without consulting a healthcare provider. If vomiting occurs within this time frame, giving another dose might result in overdosing.
Choice C Reason:
Administering cool, humidified oxygen via nasal cannula can be beneficial for an infant with heart failure, as it helps in providing supplemental oxygen and maintaining adequate oxygenation levels.
Choice D Reason:
Providing less frequent, higher volume feedings might not be appropriate for an infant with heart failure. These infants often require smaller, more frequent feedings to prevent overloading the digestive system and to manage fluid intake.
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