A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

Initiate contact precautions.

Perform chest percussion and postural drainage.

Encourage clear liquids by mouth.

Administer IV antibiotics.

Answer and Explanation

The Correct Answer is A

A. Initiate contact precautions: RSV is a highly contagious respiratory virus spread via droplets and direct contact. To prevent transmission to others, contact precautions should be initiated.
B. Perform chest percussion and postural drainage: While these techniques can be used in some respiratory conditions, they are not the first-line intervention for RSV.
C. Encourage clear liquids by mouth: While oral rehydration may be appropriate in some cases of mild dehydration, this infant is likely experiencing respiratory distress, and oral intake may be difficult. Intravenous fluids may be required, especially if the infant is having difficulty feeding.
D. Administer IV antibiotics: RSV is caused by a virus, not a bacterial infection, so antibiotics are not effective in treating the infection.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Feed infant in a supine position: Contraindicated

Supine feeding increases the risk of aspiration and exacerbates reflux.

Offer smaller, more frequent feedings: Appropriate

Smaller, frequent feedings reduce gastric distension and reflux episodes.

Thicken formula feedings with rice cereal: Appropriate

Thickened feedings can help reduce reflux by increasing the weight of the stomach contents.

Place infant in a side-lying position for sleep: Contraindicated

The recommended sleep position for infants is supine (on the back) to reduce the risk of sudden infant death syndrome (SIDS).

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The infant is at risk for developing aspiration pneumonia and esophageal strictures.

Rationale:

Aspiration pneumonia: GER can cause stomach contents to enter the respiratory tract, leading to aspiration pneumonia.
Esophageal strictures: Chronic irritation from stomach acid can result in scarring and narrowing of the esophagus.

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A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the infant. The nurse is providing teaching to the parents of the infant. For each instruction, click to specify if the instruction is appropriate or contraindicated for the infant.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

The nurse is continuing to care for the infant. Exhibits Drag words from the choices below to fill in each blank in the following sentence. Based on the findings in the infant's electronic medical record, the nurse determines that the infant is at risk for developingdropdownanddropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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