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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Placing the child in a supine position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.

B. A semi-Fowler's position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.

C. Correct. Placing the child in a lateral position allows for better access to the spinal canal, which is necessary for a lumbar puncture.

D. Placing the child in a prone position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.

A. Jacket B. Elbow C. Mummy D. Mitten

Correct Answer is C

Explanation

A. Jacket restraints are typically used to secure a child's arms during procedures. They are not specifically designed for venipuncture in infants.
B. Elbow restraints are used to secure the child's elbows, often during procedures involving the upper body. They are not typically used for venipuncture.
C. The mummy restraint is specifically designed to secure an infant's arms during venipuncture. It wraps the arms snugly, allowing access to the veins while minimizing movement.
D. Mitten restraints are used to prevent the child from manipulating equipment or accessing areas that should be restricted. They are not designed for venipuncture procedures.

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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?

Nursing Test Bank

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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?