The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading?
Chief complaint.
Review of systems.
Present illness.
Birth history.
The Correct Answer is D
The correct answer is choice D. Birth history.
Choice A rationale:
The heading "Chief complaint" is used to document the primary reason for the patient seeking medical attention, such as their main symptom or concern. This is usually stated in the patient's own words and provides context for the visit, but it does not encompass information about the circumstances of birth or prematurity.
Choice B rationale:
"Review of systems" involves a systematic approach to inquire about the patient's current symptoms or physical complaints across different body systems. It helps to identify any additional issues the patient might not have mentioned initially, but it does not pertain to birth history or prematurity.
Choice C rationale:
"Present illness" is the section where the nurse documents the patient's current health concern, including the details of the symptoms, their onset, duration, and any associated factors. However, it does not encompass information about the circumstances of birth or prematurity.
Choice D rationale:
"Birth history" is the most appropriate heading for recording information about the infant's delivery, including any difficulties during delivery and the fact that the baby was born prematurely. This information is relevant for understanding the infant's medical background and potential risk factors associated with prematurity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Epinephrine.
Choice A rationale:
Diphenhydramine. Diphenhydramine is an antihistamine commonly used to relieve allergic symptoms such as itching, rash, and runny nose. While it can be part of the treatment for anaphylactic reactions, it is not the medication of choice for immediate administration in the case of a severe anaphylactic reaction like the one described in the scenario.
Choice B rationale:
Epinephrine. Correct Answer. In cases of severe anaphylactic reactions, epinephrine (adrenaline) is the medication of choice for immediate administration. Epinephrine acts rapidly to reverse life-threatening symptoms, such as airway constriction, low blood pressure, and hives. It works by dilating airways, increasing heart rate, and improving blood pressure.
Choice C rationale:
Dopamine. Dopamine is a medication used to increase blood pressure and cardiac output in certain critical situations. However, it is not the first-line treatment for anaphylactic reactions. Epinephrine's effects on airway and cardiovascular function make it the preferred choice in this context.
Choice D rationale:
Calcium chloride. Calcium chloride is not the appropriate medication for treating anaphylactic reactions. Its main medical uses include treating hypocalcemia (low blood calcium levels) and certain cardiac arrhythmias. It does not address the primary symptoms and physiological changes associated with anaphylaxis.
Correct Answer is ["A","B","D"]
Explanation
The correct answers are choices A, B, and D.
Choice A rationale:
Applying petroleum jelly to the suture line is a necessary intervention in an infant's postoperative plan of care following cleft lip repair. Petroleum jelly helps to keep the suture line moist and prevents it from sticking to clothing or linens. This promotes proper healing and reduces the risk of trauma to the surgical site.
Choice B rationale:
Using elbow restraints is important to prevent the infant from accidentally touching or scratching the surgical site. Infants are not always able to control their movements effectively, and they may inadvertently disrupt the healing process by touching the suture line. Elbow restraints help maintain the integrity of the surgical site.
Choice C rationale:
While positioning is important in the care of a postoperative infant, supine and side-lying positions are not specific interventions related to cleft lip repair. These positions may be used for general comfort and to prevent complications such as aspiration, but they are not directly related to the surgical site.
Choice D rationale:
Mouth irrigations are not typically recommended in the postoperative care of an infant following cleft lip repair. The surgical site is in the area of the lip, not the mouth, so mouth irrigations are not directly relevant to this procedure.
Choice E rationale:
Postural drainage is not a necessary intervention for an infant following cleft lip repair. Postural drainage is a technique used to help clear mucus and secretions from the lungs in patients with respiratory conditions. It is not applicable to the care of an infant recovering from cleft lip surgery.
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