A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?

Decreased stridor

Increased restlessness

Decreased heart rate

Decreased temperature

Answer and Explanation

The Correct Answer is B

A. Decreased stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a narrowed or partially obstructed airway. In laryngotracheobronchitis, stridor is often present and may worsen with increasing airway obstruction. Therefore, decreased stridor would not be a typical finding associated with airway obstruction in this condition.

B. Increased restlessness: Increased restlessness can be a sign of worsening respiratory distress and impending airway obstruction. As the child struggles to breathe, they may become increasingly agitated and restless, indicating the need for prompt intervention to ensure adequate oxygenation.

C. Decreased heart rate: Decreased heart rate (bradycardia) is not typically associated with airway obstruction in laryngotracheobronchitis. In fact, the heart rate may increase as a compensatory response to hypoxia and respiratory distress.

D. Decreased temperature: Changes in temperature are not typically associated with airway obstruction in laryngotracheobronchitis. The focus of monitoring in this condition is primarily on respiratory distress and signs of worsening airway obstruction.

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

Explanation

A. Keep the infant in a side-lying position.

This intervention is not appropriate following cleft palate repair surgery. Placing the infant in a side-lying position may increase the risk of trauma to the surgical site and disrupt the healing process. It's important to follow the surgeon's recommendations regarding positioning, which typically involves keeping the infant in an upright position to minimize strain on the surgical site.

B. Remove elbow restraints while the infant is sleeping.

Elbow restraints are often used postoperatively to prevent the infant from accidentally touching or rubbing the surgical site, which could disrupt wound healing or cause discomfort. Removing the restraints while the infant is sleeping may increase the risk of unintended movement or injury to the surgical site. Therefore, it is not appropriate to remove the restraints while the infant is sleeping.

C. Administer pain medication around the clock for the first 72 hours.

This intervention is appropriate. Pain management is an essential component of postoperative care following cleft palate repair surgery. Administering pain medication around the clock helps to maintain consistent pain relief and prevent spikes in discomfort. Pain management should be tailored to the individual needs of the infant and may include both non-pharmacological measures and analgesic medications.

D. Feed the infant half-strength formula for the first 48 hours.

This intervention is appropriate. Following cleft palate repair surgery, feeding may need to be adjusted to accommodate the infant's comfort and ensure adequate nutrition while minimizing the risk of aspiration. Feeding the infant half-strength formula or other appropriate feeding methods as recommended by the healthcare provider can help prevent stress on the surgical site and reduce the risk of complications such as aspiration pneumonia.

A. 300ml/hour B. 100 mL/hour C. 50mL/hour D. 200 ml/hour

Correct Answer is B

Explanation

Infusion rate (mL/hour) = Total volume (mL) / Total time (hours)

Given:

Child's weight: 10 kg

Ordered volume: 40 mL/kg

Total time: 4 hours

First, calculate the total volume of Lactated Ringer's solution needed:

Total volume = 40 mL/kg × 10 kg = 400 mL

Then, divide the total volume by the total time to find the infusion rate:

Infusion rate = 400 mL / 4 hours = 100 mL/hour

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A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?

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

Explanation

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Correct Answer is B

Explanation

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