A nurse is conducting discharge and teaches parents about the care of their infant after cardiac surgery.
The nurse instructs the parents to notify the physician if the conditions occur. (Select all that apply.)
Respiratory rate of 36 breaths/minute at rest
Appetite slowly increasing
Temperature above 37.7° C (100° F)
New, frequent coughing
Turning blue or bluer than normal
Correct Answer : C,D,E
The parents should notify the physician if the infant has a temperature above 37.7° C (100° F), new frequent coughing, or turning blue or bluer
than normal. These are signs of infection, respiratory distress, or cyanosis, which could indicate complications after cardiac surgery.
Choice A is wrong because a respiratory rate of 36 breaths/minute at rest is within the normal range for an infant.
Choice B is wrong because an appetite slowly increasing is a positive sign of recovery and does not require immediate attention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
choice D. Make a follow-up home visit to parents as soon as possible after the infant’s death. This is because a competent, qualified professional should visit the family at home as soon as possible after the death and provide the family with printed information about SIDS.
Choice A is wrong because explaining how SIDS could have been predicted and prevented is inappropriate.
SIDS cannot be prevented or predicted. Discussions about the cause will only increase parental guilt.
Choice B is wrong because the parents should be asked only factual questions to determine the cause of death. Interviewing parents in-depth concerning the circumstances surrounding the infant’s death may be intrusive and stressful.
Choice C is wrong because parents should be allowed and encouraged to make a last visit with their infant. Discouraging parents from making a last visit with the infant may deprive them of an opportunity to say goodbye and grieve.
Correct Answer is C
Explanation
Visible peristalsis and weight loss. These are symptoms of pyloric stenosis, which is a thickening or narrowing of the pylorus, a muscle in the stomach that blocks food from entering the small intestine. Babies with pyloric stenosis often have forceful vomiting, which may cause dehydration.
Choice A is wrong because abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis.
They may indicate other conditions such as appendicitis or bowel obstruction.
Choice B is wrong because a rounded abdomen and hypoactive bowel sounds are also not specific for pyloric stenosis.
They may be seen in other causes of vomiting or abdominal distension.
Choice D is wrong because distention of the lower abdomen and constipation are not related to pyloric stenosis.
They may be due to other problems such as Hirschsprung’s disease or intestinal atresia. Normal ranges for weight gain in infants depend on their age, sex, and feeding method. Generally, infants should gain about 25 to 35 grams per day in the first 3 months of life.
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