A nurse is caring for a 2-month-old infant with heart failure. Which of the following actions should the nurse take?
Limit oral feedings to about 30 minutes in length
Check the infant’s oxygen saturation every 6 hours
Weigh the infant every other day
Place the infant in the prone position for naps
The Correct Answer is A
A. Correct – Infants with heart failure experience fatigue during feeding, leading to poor weight gain. Limiting feeding time reduces energy expenditure.
B. Incorrect – Oxygen saturation should be checked more frequently than every 6 hours, especially if the infant has cyanosis or respiratory distress.
C. Incorrect – Daily weight monitoring is necessary to assess fluid status and nutritional intake.
D. Incorrect – The infant should be placed on their back for naps to prevent sudden infant death syndrome (SIDS).
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
The client is at highest risk for developing mastitis evidenced by the client's cracked nipple.
Rationale:
Mastitis is a breast infection that can occur in breastfeeding individuals, often caused by bacteria entering through cracked or damaged nipples.
The client reports nipple discomfort throughout feeding and has a visible crack on the left nipple, which increases the risk of infection.
Mastitis symptoms include breast pain, swelling, redness, fever, and flu-like symptoms. If untreated, it can lead to an abscess.
Incorrect Options:
Endometritis is an infection of the uterine lining, but the client has no uterine tenderness, fever, or foul-smelling lochia, making this unlikely.
Perineal hematoma is a collection of blood in the perineal area, often presenting with severe pain and pressure. The client only reports mild perineal discomfort (2/10), which is not suggestive of a hematoma.
Correct Answer is C
Explanation
A. Incorrect – While parental support may be helpful, obtaining permission or direct parental involvement is not always appropriate or necessary.
B. Incorrect – The adolescent’s concerns are financial, not necessarily mental health-related, so referring her to a mental health clinic is not the priority intervention.
C. Correct – Medicaid provides financial assistance for prenatal care, delivery, and postpartum care for low-income pregnant individuals.
D. Incorrect – Adoption is a personal choice, and the nurse should provide support and resources rather than advising the client on a specific course of action.
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