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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
An epiphyseal fracture is a fracture that occurs in the epiphyseal plate, which is the layer of cartilage between the end of a long bone and the start of the bone shaft.
This type of fracture is most common in children and adolescents, as their bones are still growing and the epiphyseal plate is not yet fused to the bone shaft.
Because this is where new bone develops, injuries to this area can cause the plate to close prematurely, jeopardizing bone growth.
Choice B, “Bone marrow can be lost through the fracture,” is incorrect because
bone marrow is not lost through an epiphyseal fracture.
Choice C, “The younger the child the longer the healing process will take,” is incorrect because younger children generally heal faster than older children or adults.
Choice D, “The blood supply to the bone is disrupted,” is incorrect because an
epiphyseal fracture does not necessarily disrupt the blood supply to the bone.
Correct Answer is D
Explanation
Contact the provider to clarify the dosage and frequency of medication administration.
The nurse should always verify the dosage and frequency of medication administration with the provider before administering any medication to ensure the safety and well-being of the infant.
Choice A is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
Choice B is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
Choice C is not an answer because waiting and monitoring the infant’s symptoms does not address the need to verify the dosage and frequency of medication administration with the provider.
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