A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide.
Which of the following findings is the nurse's priority?
Negative doll's eye reflex
Sunken anterior fontanel
Potassium 5.1 mEq/L
Heart rate 162/min
The Correct Answer is D
A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.
B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement demonstrates understanding. Elevating the broken arm on pillows can help reduce swelling and promote comfort during the night.
B. Limiting the use of the fingers of the broken arm is important for proper healing.
However, the client should still engage in gentle range-of-motion exercises as instructed by the healthcare provider.
C. Expecting some degree of swelling in the fingers is normal after the application of a cast. This statement shows understanding.
D. Sprinkling baby powder into the cast if the arm itches is not recommended. It can cause irritation and is not an effective way to address itching under the cast. The client should be instructed not to insert anything into the cast.
Correct Answer is B
Explanation
A. The first dose of the Hepatitis B vaccine is typically administered shortly after birth, not at 12 months of age.
B. Correct. The first dose of the Varicella (chickenpox) vaccine is recommended at 12 months of age.
C. The Human Papillomavirus (HPV) vaccine is not typically started until the preadolescent or adolescent years, typically around ages 11-12.
D. The first dose of the Inactivated Polio Virus (IPV) vaccine is usually given at 2 months of age, with additional doses at 4 months and 6-18 months.
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