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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- G: 4 pregnancies (2017 spontaneous abortion, 2018 twins with one demise, 2020 NSVD, and the current pregnancy)
- T: 2 term births (2020 and 2022)
- P: 1 preterm birth
- A: 1 abortion/miscarriage (2017 spontaneous abortion)
- L: 4 living children (twins from 2018 and the child born in 2020)
Correct Answer is D
Explanation
A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.
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