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 B

Explanation

A. Sunken fontanels: Sunken fontanels are typically associated with dehydration rather than abusive head trauma.
B. Retinal haemorrhage: Retinal haemorrhages are a key indicator of abusive head trauma, such as shaken baby syndrome. They are caused by the shearing forces of rapid acceleration and deceleration.
C. Laceration to forearm: While concerning, a laceration to the forearm is not specific to abusive head trauma and could result from various types of trauma.
D. Large bruises on the body: While large bruises might indicate physical abuse, they are not specific to head trauma and do not point as directly to abusive head trauma as retinal haemorrhages do.

A. I'll expect the plastic ring to fall off by itself within a week B. I'll apply the petroleum jelly to his penis with diaper changes C. I'll make sure his diaper is loose in the front D. I'll wash his penis with warm water and mild soap each day E. I'll call the doctor if I see any bleeding

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

Explanation

A. I'll expect the plastic ring to fall off by itself within a week. This is correct; the Plastibell ring typically falls off within 5-8 days.
B. I'll apply petroleum jelly to his penis with diaper changes. Incorrect for Plastibell, because the plastic ring itself protects the site, and petroleum jelly can interfere with healing.
C. I'll make sure his diaper is loose in the front. This helps avoid pressure and irritation on the circumcised area.
D. I'll wash his penis with warm water and mild soap each day. Incorrect; the area should be kept clean but only water should be used to avoid irritation.
E. I'll call the doctor if I see any bleeding. Any significant bleeding should be reported to the healthcare provider immediately.

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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

A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?

Correct Answer is B

Explanation

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique. Which of the following client statements indicates an understanding of her son's circumcision care? (Select All that Apply.)

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

Explanation

Which of the following factors would the nurse identify as risk factors for abuse in children? (Select All that Apply.)

Which assessment finding would the nurse expect to find in a sexually active adolescent female concerned that she has contracted gonorrhea?

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