A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician of what 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 : A,C,D,E
The correct answer is choices A, C, D, and E.
Choice A rationale:
A respiratory rate of 36 breaths/minute at rest is concerning in a pediatric client, as it may indicate respiratory distress or an underlying respiratory condition.
Choice B rationale:
An increasing appetite is generally a positive sign and not typically concerning unless accompanied by other symptoms.
Choice C rationale:
A temperature above 37.7° C (100° F) is concerning as it indicates fever, which could be a sign of infection or other medical conditions.
Choice D rationale:
New, frequent coughing is concerning as it may indicate respiratory infections, asthma, or other respiratory issues.
Choice E rationale:
Turning blue or bluer than normal (cyanosis) is a serious symptom indicating inadequate oxygenation and requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Applying oil-based lotion is not recommended during phototherapy as it can block the pores and reduce the effectiveness of the therapy. The baby's skin should be exposed to the light as much as possible to treat hyperbilirubinemia effectively.
Choice B rationale:
Limiting the newborn's intake of milk is not appropriate. Adequate hydration and nutrition are essential for infants, especially those undergoing phototherapy. Dehydration can worsen jaundice, so the baby should be encouraged to feed frequently.
Choice C rationale:
Placing eye shields over the newborn's closed eyes is essential during phototherapy. Exposure to high-intensity light can damage the baby's eyes, so protecting the eyes with shields is necessary.
Choice D rationale:
Changing the newborn's position every 2-3 hours is recommended during phototherapy. This helps ensure that all parts of the baby's skin receive equal exposure to the light, maximizing the effectiveness of the treatment.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
Correction of acidosis is not the primary intervention for vaso-occlusive sickle cell crisis. The crisis primarily involves pain due to the obstruction of blood flow by sickled cells. Correcting acidosis is not a direct treatment for this condition.
Choice B rationale:
Adequate hydration is essential in managing vaso-occlusive sickle cell crisis. Proper hydration helps prevent dehydration, which can worsen the crisis and lead to complications. Hydration helps maintain blood flow and prevent further sickling of red blood cells.
Choice C rationale:
Pain management is a crucial intervention for a child with vaso-occlusive sickle cell crisis. Pain results from tissue ischemia caused by sickled red blood cells. Effective pain management, often with analgesics, helps improve the child's comfort and quality of life during the crisis.
Choice D rationale:
Administration of heparin is not indicated for vaso-occlusive sickle cell crisis. Heparin is an anticoagulant that prevents blood clot formation. In sickle cell crisis, the primary issue is the obstruction of blood flow by sickled cells, not the formation of clots. Administering heparin may not address the underlying problem and can lead to potential complications.
Choice E rationale:
Replacement of factor VIII is not relevant to vaso-occlusive sickle cell crisis. Factor VIII is a protein involved in blood clotting and is primarily used in the treatment of hemophilia, a different condition unrelated to sickle cell crisis.
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