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. An adolescent in skin traction reporting a pain level of 7 requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
B. This client should be assessed first. Slurred speech in an adolescent with sickle cell anemia is a potential sign of a cerebral event, such as a stroke or a transient ischemic attack (TIA), and requires immediate evaluation.
C. The toddler with a new diagnosis of osteomyelitis requiring an IV bolus of nafcillin should be assessed promptly, but this is not as urgent as the potential neurological symptom described in option B.
D. The toddler with a partial-thickness burn on the right hand requiring a dressing change also requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
Correct Answer is C
Explanation
A. Hypertension is not a typical finding in severe dehydration. In fact, dehydration often leads to decreased blood pressure.
B. Increased urine output is not a typical finding in severe dehydration. Dehydration leads to decreased urine output as the body tries to conserve fluids.
C. This is the correct answer. In severe dehydration, the body compensates by increasing the respiratory rate to try to maintain oxygen levels and remove excess carbon dioxide. This is a compensatory mechanism in response to metabolic acidosis, which can occur with dehydration.
D. A capillary refill of 2 seconds indicates normal perfusion. In severe dehydration, capillary refill may be prolonged, indicating poor perfusion.
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