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 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 : A,G
A. Teach caregivers to change diapers when wet.
✅ Correct. Prevents skin breakdown and diaper dermatitis.
B. Have caregivers administer 16 oz of water after each diarrhea stool.
❌ Incorrect. Infants should not get plain water in such amounts. Risk of water intoxication & electrolyte imbalance. Oral rehydration solutions (ORS) or breast milk/formula are recommended instead.
C. Cleanse the diaper area with soap and water.
❌ Incorrect. Harsh soaps can irritate the skin. Best practice: gentle cleansing with warm water or mild wipes, and barrier ointment if needed.
D. Collect nasal drainage for culture and sensitivity.
❌ Incorrect. Only done if ordered and if infection is suspected. At follow-up (Visit #2), infant is afebrile and stable—no need for culture.
F. Teach caregivers to apply talcum powder to creases.
❌ Incorrect. Talcum powder is contraindicated in infants (risk of aspiration & respiratory issues). Barrier creams preferred.
G. Use a nasal aspirator after feedings.
✅ Correct. Safe and effective to clear nasal secretions and prevent aspiration or feeding difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Infants with spina bifida are at an increased risk of developing a latex allergy
due to repeated exposure to latex products during medical procedures.
Providing a latex-free environment can help prevent the development of an allergy.
Choice A is not correct because limiting visitors to immediate family members is not necessary for the care of an infant undergoing surgical closure of the myelomeningocele sac.
Choice B is not correct because maintaining the infant in the supine position is not necessary for this procedure.
Choice D is not correct because initiating contact precautions is not necessary for this procedure.
Correct Answer is D
Explanation
A. Semi-Fowler's. While this position can help with drainage, it is generally not the first choice immediately after VP shunt surgery.
B. Prone.This position is generally not recommended as it can cause discomfort and increase intracranial pressure.
C. Trendelenburg. This position is contraindicated as it can significantly increase intracranial pressure.
D. on the unoperated side. This position helps prevent pressure on the operative site and facilitates drainage of cerebrospinal fluid. It also reduces the risk of complications associated with increased intracranial pressure.
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