When caring for an infant with an upper respiratory tract infection and elevated temperature, which appropriate nursing intervention should the nurse implement?
Give tepid water baths to reduce fever.
Encourage food intake to maintain caloric needs.
Have child wear heavy clothing to prevent chilling.
Give small amounts of favorite fluids frequently to prevent dehydration.
The Correct Answer is D
Give small amounts of favorite fluids frequently to prevent dehydration.
Dehydration is a common complication of upper respiratory tract infections in infants, especially if they have a fever. Giving small amounts of fluids frequently can help maintain hydration and electrolyte balance.
Some additional information about the other choices are:
Choice A is wrong because tepid water baths are not recommended for fever reduction. They can cause shivering, which increases heat production and can raise the
temperature further. Instead, antipyretics such as acetaminophen or ibuprofen can be given as prescribed.
Choice B is wrong because food intake may be decreased due to poor appetite, difficulty breathing, or sore throat. Forcing food intake can cause vomiting or aspiration. Fluid intake is more important than caloric intake during an acute infection.
Choice C is wrong because heavy clothing can increase heat retention and discomfort. The infant should be dressed in light clothing and the room temperature should be comfortable.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
choice D. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia. This is because a macrosomic infant (a newborn who’s much larger than average) is at risk of developing low blood sugar levels after birth, especially if the mother has diabetes. Hypoglycemia can cause neurological damage in the newborn, so it is important to detect and treat it promptly.
Choice A is wrong because leaving the infant in the room with the mother without monitoring the blood glucose levels may miss signs of hypoglycemia and delay treatment.
Choice B is wrong because taking the infant immediately to the nursery may separate the infant from the mother and interfere with breastfeeding, which can help prevent hypoglycemia.
Choice C is wrong because performing a gestational age assessment to determine whether the infant is large for gestational age is not urgent and does not address the risk of hypoglycemia.
Normal ranges for blood glucose levels in term infants are 2.6 mmol/L or higher at any time. A blood glucose level of 2.5 mmol/L or less is considered hypoglycemic.
Correct Answer is D
Explanation
An Apgar score of 10 at 1 minute after birth indicates that the infant is having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. The Apgar score is a scoring system that evaluates the health of newborns at 1 and 5 minutes after birth based on five criteria: appearance, pulse, grimace, activity, and respiration. Each criterion is scored from 0 to 2, and the total score ranges from 0 to 10. A score of 7 to 10 is considered reassuring, a score of 4 to 6 is moderately abnormal, and a score of 0 to 3 is concerning.
Choice A is wrong because an Apgar score of 10 at 1 minute does not mean that the infant needs no further testing. The infant should still be assessed again at 5 minutes and monitored for any signs of distress or complications.
Choice B is wrong because an Apgar score of 10 at 1 minute does not indicate an infant in severe distress who needs resuscitation. An Apgar score of 0 to 3 would indicate a concerning condition that may require immediate intervention.
Choice C is wrong because an Apgar score of 10 at 1 minute does not predict a future free of neurologic problems. The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia or brain injury; it does not predict individual neonatal mortality or neurologic outcome; and it should not be used for that purpose.
Normal ranges for each criterion are as follows:
- Appearance (color): pink all over (2 points), body pink but extremities blue (1 point), blue, bluish-gray, or pale all over (0 points)
- Pulse (heart rate): greater than 100 beats per minute (2 points), less than 100 beats per minute (1 point), absent (0 points)
- Grimace (response to stimulation): cough or sneeze, cry and withdrawal of foot with stimulation (2 points), facial movement/grimace with stimulation (1 point), absent (0 points)
- Activity (muscle tone): active movement (2 points), limbs flexed (1 point), limp or floppy (0 points)
- Respiration (breathing): good, strong cry (2 points), irregular, weak crying (1 point), absent (0 points)
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