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.

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Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Limit oral feedings to 30 min in length.

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 the prone position can compromise the 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.

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Correct Answer is A

Explanation

Choice A reason:

Measuring the arm circumference above the insertion site daily is appropriate. When planning care for a client scheduled to receive a peripherally inserted central catheter (PICC) in the arm, it is appropriate for the nurse to include measuring the arm circumference above the insertion site daily. This intervention is essential to monitor for any signs of complications, such as edema or swelling, which could indicate thrombosis or infiltration at the insertion site.

Choice B reason:

Administering sedation Administering sedation is not a routine intervention for a PICC insertion procedure is inappropriate. Sedation might be considered for certain procedures, but it is not typically used for PICC insertions. PICC insertions are generally performed with local anaesthesia at the insertion site.

Choice C reason:

Scheduling an MRI post procedure to verify placement An MRI is not typically used to verify the placement of a PICC. The placement of a PICC is usually confirmed using X-ray or other imaging methods that can visualize the catheter's location within the central veins. Post-procedure verification of PICC placement is essential to ensure proper positioning and to prevent complications.

Choice D reason:

Using gauze to secure an arm board to the involved extremity Using gauze to secure an arm board to the involved extremity is not a common practice for securing a PICC. After a PICC insertion, a securement device specifically designed for PICCs is typically used to secure the catheter in place and prevent movement.

A. "This test will be repeated when your baby is 2 months old." B. "Your baby will be given 2 ounces of water to drink prior to the test." C. "This test should be performed after your baby is 24 hours old." D. "A nurse will draw blood from your baby's inner elbow."

Correct Answer is C

Explanation

Choice A reason:

"This test will be repeated when your baby is 2 months old. “This is a false statement. Newborn genetic screening is usually performed shortly after birth. The test is not typically repeated when the baby is 2 months old, as it is meant to detect conditions early on, allowing for prompt intervention and management if necessary.

Choice B reason:

"Your baby will be given 2 ounces of water to drink prior to the test."This is a false statement. The baby does not need to drink water before the newborn genetic screening test. The test is usually performed by collecting a small blood sample from the baby's heel, and there is no need for the baby to drink water beforehand.

Choice C reason:

"This test should be performed after your baby is 24 hours old. “This is the appropriate statement. The nurse should include the statement that newborn genetic screening should be performed after the baby is 24 hours old. Newborn genetic screening, also known as newborn screening or heel prick test, is a standard test performed on newborns to detect certain genetic, metabolic, and congenital disorders early on. The test is typically done by pricking the baby's heel to collect a small sample of blood, which is then analysed in a laboratory.

Choice D reason:

"A nurse will draw blood from your baby's inner elbow. “This is a false statement. The correct location for collecting the blood sample for newborn genetic screening is the baby's heel. The nurse will prick the baby's heel to obtain a few drops of blood, which will then be collected on a special filter paper for laboratory analysis.

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A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care?

Correct Answer is A

Explanation

nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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A nurse is caring for a 2-month-old infant who has heart failure.

Which of the following actions should the nurse take?