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 B
Explanation
A. Pinpoint pupils are a characteristic sign of opioid overdose, not inhalation of gasoline.
B. Correct. Ataxia (lack of coordination) can be a neurological symptom associated with inhalation of gasoline or other volatile substances. These substances can affect the central nervous system and lead to impaired coordination.
C. Hyperactive reflexes are not a typical finding associated with inhalation of gasoline.
This is more characteristic of conditions like hyperthyroidism or certain neurological disorders.
D. Hypothermia is not a typical finding associated with inhalation of gasoline. It is more likely to cause symptoms related to the central nervous system and respiratory system.
Correct Answer is B
Explanation
A. Allowing the child to watch an animated movie right before bedtime can be stimulating and may not be conducive to a calm and restful sleep environment.
B. This is correct. Allowing the child to sleep in the parent's bed may reinforce the night terrors. It's important for the child to learn to self-soothe and feel secure in their own sleeping environment.
C. It is not recommended to wake a child during a night terror. This can be disorienting and may not be effective in preventing future night terrors.
D. Waiting until the child indicates tiredness before putting them to bed may result in over-tiredness, which can sometimes contribute to night terrors. Establishing a consistent bedtime routine can be beneficial.
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