The nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this infant? (Select All that Apply.)

Maintain a thermoneutral environment

Accurately measure all intake and output

Provide for several periods of uninterrupted rest

Incentive spirometer 10 times every hour

Encourage periods of bonding

Answer and Explanation

Correct Answer : A,B,C,E

A. Maintain a thermoneutral environment: Helps prevent temperature fluctuations that can stress the heart post-surgery.
B. Accurately measure all intake and output: Ensures fluid balance is carefully monitored to prevent fluid overload or dehydration.
C. Provide for several periods of uninterrupted rest: Reduces metabolic demand, aiding in recovery and healing.
D. Incentive spirometer 10 times every hour: Inappropriate for infants following cardiac surgery, as they are unable to effectively use an incentive spirometer.
E. Encourage periods of bonding: Supports emotional well-being and aids in the infant's overall recovery and development.

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Correct Answer is D

Explanation

A. Keep eye shields on at all times, including when feeding. Incorrect because while eye protection is crucial under the lights, they can be removed during feedings to allow for parent-infant bonding and eye contact.
B. Routinely monitor temperature while the infant is in the crib. Incorrect, because temperature should be closely monitored while the infant is under phototherapy due to potential changes in body temperature caused by the exposure.
C. Tightly swaddle the infant in a blanket. Incorrect, as this would reduce the amount of skin exposed to the phototherapy lights and decrease the treatment's effectiveness.
D. Expose as much of the infant's skin to the lights as possible. Phototherapy is most effective when as much skin as possible is exposed to the lights because it allows for maximum light absorption and more effective bilirubin breakdown.

A. Administer Oxytocin IV per MD orders B. Notify the healthcare provider C. Document the fundal height and consistency D. Massage the fundus until it firms

Correct Answer is D

Explanation

A. Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.

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The nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this infant? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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