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 A
Explanation
Choice A rationale:
A brilliant, uniform red reflex observed during a funduscopic examination is a normal finding. It indicates the absence of any abnormalities in the retina or lens. A normal red reflex is essential in ruling out serious conditions such as retinoblastoma, cataracts, or other eye abnormalities.
Choice B rationale:
An abnormal red reflex, especially if it is not uniform and brilliant, could indicate underlying eye conditions and would require referral to an ophthalmologist for further evaluation. However, in this scenario, the description provided indicates a normal finding, making this choice incorrect.
Choice C rationale:
A uniform red reflex does not suggest a possible visual defect that requires vision screening. A normal red reflex indicates the absence of significant visual abnormalities, making this choice incorrect.
Choice D rationale:
Small hemorrhages in the eye would not present as a brilliant, uniform red reflex. Hemorrhages typically appear as dark spots or patches and would be an abnormal finding requiring further evaluation. This choice is incorrect in the context of the described scenario.
Correct Answer is B
Explanation
Choice A rationale:
Telling the patient that she should have felt the baby move by now might cause unnecessary anxiety if she hasn't experienced fetal movement yet. Fetal movement can vary, and some women might not feel it until later in their pregnancy. This statement does not provide accurate and reassuring information.
Choice B rationale:
Around 14 to 25 weeks of gestation, most women begin to feel fluttering sensations, which are the early movements of the baby. By stating that the patient should start feeling these sensations within the next month or so, the nurse provides an accurate and reassuring response based on the typical timeline for fetal movement.
Choice C rationale:
This statement is incorrect. While the baby is moving, it might not be perceivable to the mother due to various factors such as the position of the placenta or the baby's own activity patterns. Simply stating that the baby is moving does not address the patient's concern about feeling the movements.
Choice D rationale:
Some babies are indeed quiet, and their movements might not be as noticeable to the mother. However, this statement does not provide a specific timeframe or address the patient's immediate concern about when she will start feeling the baby move. It is essential to provide a more informative and reassuring response.
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