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?

heart rate 162/min

negative doll's eye reflex.

Sunken anterior fontanel

potassium 5.1MEq/L

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Sunken anterior fontanel.

Choice A rationale:

A heart rate of 162/min in a 2-month-old infant can be within the upper range of normal, especially if the infant is crying or agitated. While it is important to monitor, it is not the most critical finding in this context.

Choice B rationale:

A negative doll’s eye reflex (oculocephalic reflex) can indicate neurological issues, but it is not directly related to heart failure or the administration of furosemide.

Choice C rationale:

A sunken anterior fontanel indicates dehydration, which is a critical concern for an infant receiving furosemide, a diuretic that can lead to significant fluid loss. Dehydration can exacerbate heart failure and lead to severe complications.

Choice D rationale:

A potassium level of 5.1 mEq/L is slightly elevated but not immediately life-threatening. It requires monitoring and potential intervention but is not the most urgent issue compared to dehydration.

Monitoring for dehydration is crucial in infants on diuretics like furosemide, making the sunken anterior fontanel the priority finding.

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Correct Answer is C

Explanation

The correct answer is C.

Choice A reason: A White Blood Cell (WBC) count of 20,000/mm³ is significantly higher than the normal range for children, which is typically between 5,000 to 10,000/mm³. In the context of acute lymphoblastic leukemia (ALL), a high WBC count could indicate an active disease process or a reaction to treatment, rather than a therapeutic effect.

Choice B reason: A hemoglobin level of 5.5 g/dL is quite low, as the normal range for children is generally between 11 to 16 g/dL. This level of hemoglobin suggests anemia, which is a common condition in patients with leukemia due to the disease itself or as a side effect of chemotherapy. It does not necessarily indicate that the treatment is having a therapeutic effect.

Choice C reason: A Platelet count of 150,000/mm³ is within the lower end of the normal range for children, which is approximately 150,000 to 450,000/mm³. This can be considered a sign that the treatment is working effectively, as it indicates bone marrow recovery and the production of platelets is returning to normal levels.

Choice D reason: A Red Blood Cell (RBC) count of 3/mm³ is extremely low. The normal range for children’s RBC count is about 4 million to 5.5 million/mm³. Such a low RBC count would indicate severe anemia and is not a sign of effective treatment for ALL.

A. Provide a pacifier coated with an oral sucrose prior to injections B. Inject the immunizations into the deltoid muscle C. Use as 20-gauge needle for injections D. Apply eutectic mixture of local anesthetics cream immediately before the injections .

Correct Answer is ["A","D"]

Explanation

Choice A rationale

Providing a pacifier coated with an oral sucrose prior to injections can help reduce the infant’s pain response. The sweetness of the sucrose can distract the infant and provide some comfort.

Choice B rationale

Injecting the immunizations into the deltoid muscle is not recommended for infants. The deltoid muscle is not usually used until children are older and have more muscle mass.

Choice C rationale

Using a 20-gauge needle for injections is not typically recommended for infants. Smaller gauge needles are usually used to minimize discomfort.

Choice D rationale

Applying a eutectic mixture of local anesthetics cream immediately before the injections can help numb the skin and reduce pain. This can make the injection process less distressing for the infant.

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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?

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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?