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Exhibits

Review H and P, laboratory results, flow sheet, and orders.

The nurse notifies the health care provider of the lab values, blood pressure and pulse, and current intake and output.

Which prescriptions does the nurse expect the healthcare provider to write based on the information? Select all that apply.

Turn off the suction on the nasogastric tube

Bolus calcium

Increase the intravenous fluid rate

Add potassium to the intravenous fluids

Administer a diuretic

Flush the central line with 3% sodium chloride

Decrease the percentage of sodium in the intravenous fluids

Answer and Explanation

Correct Answer : A,C,D

A.   Turn off the suction on the nasogastric tube. The client has been experiencing continuous nasogastric (NG) suction, which can lead to fluid and electrolyte imbalances. The client's low blood pressure (86/64 mm Hg), leg cramping, and fatigue suggest volume depletion and possible electrolyte loss. Discontinuing NG suction will help prevent further fluid loss and electrolyte depletion.
B.   Bolus calcium. The client’s calcium levels (9.2 mg/dL and 9.1 mg/dL) are within normal range (8.5–10.2 mg/dL). Since there is no indication of hypocalcemia, a calcium bolus is not necessary.
C.   Increase the intravenous fluid rate. The client’s low blood pressure, tachycardia (96 bpm), and signs of fatigue suggest hypovolemia, likely due to fluid losses from NG suction and inadequate IV fluid replacement. Increasing IV fluid rate can help restore circulatory volume and improve perfusion.
D.   Add potassium to the intravenous fluids. The client’s potassium level has dropped from 3.8 mEq/L to 3.5 mEq/L, which is at the lower limit of normal (3.5–5.0 mEq/L). Prolonged NG suctioning can cause hypokalemia, leading to muscle cramps, weakness, and fatigue. Adding potassium to IV fluids can prevent further decline and correct the deficiency.
E.   Administer a diuretic. The client is already hypovolemic due to NG losses, as evidenced by low blood pressure and tachycardia. A diuretic would further exacerbate volume depletion, making it an inappropriate intervention.
F.   Flush the central line with 3% sodium chloride. The client's sodium levels are normal (139–142 mEq/L), so a hypertonic saline flush (3% NaCl) is not needed. This type of fluid is typically used for severe hyponatremia, which is not present in this case.
G.   Decrease the percentage of sodium in the intravenous fluids. The client is receiving Dextrose 5% in 0.9% sodium chloride, which provides isotonic hydration. Since the sodium level is within normal limits and the client is hypovolemic, reducing sodium concentration in IV fluids is not necessary.

Nursing Test Bank

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Correct Answer is ["A","E","F"]

Explanation

A. Hunger – The infant is NPO postoperatively but is accustomed to regular feedings. Hunger-related distress is common in infants after surgery, especially when oral intake is restricted. Since the infant has a history of GERD and fundoplication surgery, feedings are likely delayed to prevent complications, contributing to crying.
B. Opioid withdrawal – There is no indication that the infant has been on chronic opioid therapy before surgery. Opioid withdrawal symptoms typically occur in infants exposed to opioids for prolonged periods (e.g., neonatal abstinence syndrome), which is not relevant in this case.
C. Hemorrhage – The surgical dressing is clean and dry, meaning there are no visible signs of bleeding at the incision site. If significant internal bleeding were occurring, the infant would likely show signs of pallor, tachycardia, and hypotension, which are not present.
D. Separation anxiety – Separation anxiety typically develops around 6–9 months of age, when infants become more aware of their caregivers' presence. At 4 months, infants can recognize caregivers but do not yet exhibit true separation distress, making this an unlikely reason for crying.
E. Pain – Postoperative pain is a common cause of crying in infants after surgery. Signs of pain in nonverbal infants include crying, facial grimacing, irritability, and body tension. Since the infant has just undergone fundoplication surgery, pain is a likely contributing factor.
F. Hypovolemia – The infant is receiving IV fluids (Dextrose 5% with sodium chloride 0.45%), but fluid deficits can still occur postoperatively due to preoperative fasting, surgical fluid losses, or inadequate replacement. Hypovolemia can cause discomfort, irritability, tachycardia, and crying.
G. Hypoxia – The infant is described as pink and well-perfused with clear breath sounds, which rules out respiratory distress as a likely cause of crying. If hypoxia were present, signs such as cyanosis, increased work of breathing, or abnormal breath sounds would be expected.

A. Encourage breastfeeding every 2 to 3 hours. B. Administer antibiotics for 7 to 10 days. C. Give zidovudine 6 to 12 hours after birth. D. Delay the initial bath for 1 to 2 days.

Correct Answer is C

Explanation

A. Encourage breastfeeding every 2 to 3 hours. Breastfeeding is contraindicated in HIV-positive mothers in regions where safe formula feeding is available, as HIV can be transmitted through breast milk. Instead, formula feeding is recommended to prevent vertical transmission of the virus.
B. Administer antibiotics for 7 to 10 days. Routine antibiotic prophylaxis is not necessary for newborns born to HIV-positive mothers. Instead, the focus is on antiretroviral therapy (ART) to reduce the risk of HIV transmission. Antibiotics would only be indicated if there is a confirmed or suspected infection.
C. Give zidovudine 6 to 12 hours after birth. Newborns of HIV-positive mothers should receive zidovudine (AZT) as post-exposure prophylaxis within the first 6 to 12 hours after birth to reduce the risk of perinatal HIV transmission. The duration of therapy depends on the infant’s risk level, with high-risk infants receiving combination antiretroviral therapy.
D. Delay the initial bath for 1 to 2 days. The newborn should be bathed as soon as their temperature is stable to remove maternal blood and amniotic fluid, which could contain the virus. Early bathing reduces the risk of viral exposure through mucous membranes or breaks in the skin.

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse is reviewing the assessment data. Which are the 3 most likely reasons that the infant is crying?

Correct Answer is ["A","E","F"]

Explanation

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?

Correct Answer is C

Explanation

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

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Upon completion of a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse prepares the family for discharge. Which information should the nurse include?

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