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 ["A","D","E"]

Explanation

A. Handwashing. Good hygiene is important to prevent the spread of the virus, especially after touching the lesions.
B. Gardasil injection. Gardasil is a vaccine for HPV, not HSV. It is not relevant for the management of herpes.
C. Penicillin. Penicillin is not effective against viral infections like herpes; antiviral medications such as acyclovir are used for treatment.
D. Use of barrier protection. Barrier methods such as condoms are crucial in reducing the risk of transmission of HSV-2 to sexual partners.
E. Perineal care of genital lesions. Proper care of lesions can help reduce discomfort and prevent secondary infections.

A. Vernix in the folds and creases B. Short, soft fingernails C. Abundant lanugo D. Cracked, peeling skin E. Creases covering soles of feet F. Positive moro reflex

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

Explanation

A. Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.

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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 ["A","D","E"]

Explanation

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

Explanation

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