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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Abdominal respirations do not directly predispose toddlers to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections. Abdominal respirations are a normal breathing pattern in toddlers, transitioning from the diaphragmatic breathing seen in infants. This change is due to the toddler's increased chest wall compliance and stronger intercostal muscles, facilitating more efficient breathing.
Choice B rationale:
Slower pulse and respiratory rates in toddlers compared to infants are part of normal physiological development. Toddler's heart rates range from 70 to 110 beats per minute, and respiratory rates range from 20 to 30 breaths per minute. These rates are considered normal for toddlers and do not predispose them to frequent infections.
Choice C rationale:
Toddlers do have less efficient defense mechanisms than infants, making them more susceptible to infections. This is due to the immature immune system in toddlers, which is still developing and learning to respond to various pathogens. However, this choice is not the most important factor predisposing toddlers to frequent infections; other factors play a more significant role.
Choice D rationale:
The presence of short, straight internal ear/throat structures and large tonsil/adenoid lymph tissue in toddlers is the most important factor predisposing them to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections. These anatomical features make it easier for bacteria and viruses to enter and infect the respiratory and ear passages, leading to recurrent infections.
Correct Answer is B
Explanation
Choice A rationale:
Inspiratory stridor. Inspiratory stridor, a high-pitched sound heard during inhalation, is a common symptom of acute epiglottitis. It is caused by the swelling and inflammation of the epiglottis, which can partially obstruct the airway and create a stridor sound during breathing.
Choice B rationale:
Complete obstruction. Using a tongue depressor to examine the throat of a child with acute epiglottitis can potentially lead to a complete airway obstruction. The epiglottis, which is already swollen, can block the airway entirely, leading to respiratory distress and potentially a life-threatening situation.
Choice C rationale:
Sore throat. A sore throat is a common symptom of various respiratory tract infections, including acute epiglottitis. However, the use of a tongue depressor can worsen the swelling and potentially lead to complete airway obstruction, which is a more immediate concern.
Choice D rationale:
Respiratory tract infection. Acute epiglottitis itself is a severe respiratory tract infection, specifically involving the epiglottis. Using a tongue depressor might exacerbate the condition, leading to airway obstruction, but it is not the cause of the respiratory tract infection.
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