A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take?
Limit oral feedings to 30 min in length.
Weigh the infant every other day.
Place the infant in the prone position for naps.
Check the infant’s oxygen saturation every 6 hr.
The Correct Answer is A
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in a prone position can compromise respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choicea. Maternal hypoglycemia.
Choice A rationale:
Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia.The fetus relies on maternal glucose for energy, and a significant drop in maternal glucose levels can affect the fetal heart rate.
Choice B rationale:
Maternal fever is typically associated with fetal tachycardia rather than bradycardia.An elevated maternal temperature can increase the fetal heart rate as the fetus attempts to regulate its own temperature.
Choice C rationale:
Chorioamnionitis, an infection of the amniotic fluid and membranes, is also more commonly associated with fetal tachycardia due to the inflammatory response and fever.
Choice D rationale:
Fetal anemia can cause fetal tachycardia as the fetus compensates for the reduced oxygen-carrying capacity of the blood.Bradycardia is not a typical response to fetal anemia.
Correct Answer is C
Explanation
The correct answer is:
Choice C: Determine the medical needs of incoming clients through the emergency department.
Here's a breakdown of the rationale for each choice:
Choice A rationale: While calling in additional staff might be helpful in the long run, during the initial surge of patients in a mass casualty event, the Emergency Department (ED) will be the primary area receiving and triaging patients. The medical-surgical unit will likely receive overflow patients after initial stabilization in the ED.
Choice B rationale: This is not a primary responsibility for a nurse on a medical-surgical unit during a mass casualty event. Communication with the media is usually handled by designated public relations personnel.
Choice C rationale: This is the most crucial action for a nurse in this situation. Triaging patients based on the severity of their injuries and prioritizing care is essential in a mass casualty scenario. Nurses will be instrumental in assessing incoming patients relayed from the ED to determine their medical needs and allocate resources accordingly.
Choice D rationale: Discharging patients is not a priority during the initial influx of casualties. The focus is on receiving, stabilizing, and treating the most critically injured patients. Discharges would likely happen after the initial surge subsides.
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