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. Applying warm compresses can help to improve blood flow and relieve pain in areas affected by a sickle cell crisis. This is a beneficial intervention.
B. Decreasing fluid intake is not recommended. Maintaining hydration is important in the management of sickle cell disease, as it helps to prevent dehydration and reduces the risk of sickling.
C. Furosemide is a diuretic and is not typically used in the treatment of a sickle cell crisis.
It is not an appropriate intervention in this situation.
D. Contact precautions are not necessary for a sickle cell crisis. This crisis is not a contagious condition. Standard precautions for infection control should be followed.
Correct Answer is B
Explanation
A. Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) and may not require immediate reporting unless it is severe or associated with other concerning symptoms.
B. Correct. Tachypnea (rapid breathing) in an infant with RSV can be a sign of
respiratory distress and may require immediate intervention or further evaluation by the provider.
C. Pharyngitis (sore throat) is a possible symptom of RSV, but it may not be as immediately concerning as tachypnea.
D. Coughing is a common symptom of RSV and may not require immediate reporting unless it is severe or associated with other concerning symptoms.
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