A nurse is caring for an infant in a provider's office.

Medical History Provider Visit #1. Heart rate 144/min.

Axillary temperature 39.7° C (103.5°F). Respiratory rate 32/min.

Oxygen saturation 95% on room air. Provider Visit #2 (4 days later).

Axillary temperature 37.4° C (99.3° F). Heart rate 132/min.

Respiratory rate 28/min.

Oxygen saturation 97% on room air.

Which of the following actions should the nurse plan to take? Select the 3 actions the nurse should plan to take.

Teach caregivers to change diapers when wet.

Have caregivers administer 16 oz of water after each diarrhea stool.

Cleanse the diaper area with soap and water.

Collect nasal drainage for culture and sensitivity.

Teach caregivers to apply talcum powder to creases.

Use a nasal aspirator after feedings.

Answer and Explanation

Correct Answer : C,D,E

Choice C, cleanse diaper area with soap and water, is important to maintain hygiene and prevent diaper rash. This should be done at each diaper change.
Choice E, instruct caregivers to apply zinc oxide with each diaper change, is important to prevent diaper rash and promote healing if a rash is present.
Choice D, collect nasal drainage for culture and sensi vity, is important to determine if there is a bacterial infec on present, which could explain theinfant's high fever during the first provider visit.
Choice A, teach caregivers to change diaper when wet, is not necessary as it is already expected that caregivers will change the diaper when wet.
Choice B, have caregivers administer 16 oz of water a er each diarrhea stool, is not necessary as there is no indica on of diarrhea in the scenario.
Choice F, teach caregivers to apply talcum powder to creases, is not necessary as talcum powder has been associated with respiratory problems in infants and should not be used.
Choice G, use a nasal aspirator a er feedings, is not necessary as there is no indica on of nasal conges on in the scenario.

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Correct Answer is D

Explanation

The nurse should ﬁrst oﬀer the mother's private time with the newborn to allow her to grieve and say goodbye.
This can be an important part of the healing process for the mother.
Choice A is not an answer because contacting clergy is not the ﬁrst action the nurse should take.
Choice B is not an answer because transferring the client to another unit is not the ﬁrst action the nurse should take.
Choice C is not an answer because administering medication is not the ﬁrst action the nurse should take.

A. Reposition the client by log rolling every 4 hr. B. Place the client in protective isolation. C. Keep the head of the bed at a 30° angle. D. Initiate the use of a PCA pump for pain control.

Correct Answer is D

Explanation

a.Log rolling is an appropriate technique to reposition a postoperative scoliosis repair patient as it minimizes stress on the spine and helps maintain spinal alignment. Patients need frequent repositioning to prevent pressure ulcers and promote comfort, but every 4 hours may not be frequent enough; typically, every 2 hours is recommended.

b.Protective isolation is not typically required for patients undergoing scoliosis surgery unless they have specific risk factors for infection (e.g., immunocompromised status). Standard postoperative care focuses on monitoring for infection at the surgical site rather than isolation unless indicated by the patient's condition.

c.While it’s important to elevate the head of the bed to assist with breathing and comfort, after scoliosis surgery, the head of the bed is generally elevated to 30-45° to facilitate lung expansion and reduce the risk of aspiration. However, it should be ensured that this angle does not compromise spinal alignment, especially in the early postoperative period.

d.The use of a patient-controlled analgesia (PCA) pump is an appropriate intervention for pain management after scoliosis surgery. It allows the patient to self-administer pain medication within prescribed limits, leading to more effective pain management, improved patient satisfaction, and potentially reduced need for supplemental analgesics.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a mother immediately following a stillbirth delivery. Which of the following actions should the nurse take first?

Correct Answer is D

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Correct Answer is D

Explanation

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