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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Related Questions
Correct Answer is C
Explanation
A. Mannitol is used to decrease intracranial pressure but should only be given after assessing the client's neurological status.
B. An MRI can help diagnose brain injuries but is not the priority before assessing the client's condition.
C. The Glasgow Coma Scale (GCS) helps assess the severity of brain injury and is crucial in determining the immediate needs of the client.
D. A urinary catheter may be needed but is not the priority over neurological assessment.
Correct Answer is B
Explanation
A. Synthetic fabrics can generate static electricity, which can be a fire hazard around oxygen.
B. Nail polish remover contains acetone, which is flammable and should not be used near oxygen.
C. Alcohol-based cleaners are flammable and should not be used to clean oxygen equipment.
D. Petroleum-based products (e.g., petroleum jelly) should not be used, as they can increase the risk of burns in an oxygen-rich environment.
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