Nokea
The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure. The infant's vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute. Which medication should the nurse hold and inform the health care provider?
- A. Enalapril
- B. Digoxin
- C. Furosemide
- D. Hydralazine
Correct Answer: B
Rationale: The infant's apical pulse of 88 beats/minute is below the normal range (100-160 beats/minute) for an eight-month-old, indicating a need to hold Digoxin and notify the provider.
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The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?
- A. Position prone after feeding.
- B. Breastfeed frequently.
- C. Avoid smoke exposure.
- D. Inspect the infant's ears daily.
Correct Answer: C
Rationale: Avoiding smoke exposure reduces eustachian tube irritation, lowering otitis media risk.
The parents of a 14-month-old child, hospitalized due to febrile seizures, express their concern to the nurse about their child having seizures for life. What information should the nurse share with these parents?
- A. Avoid overstimulation as it can trigger seizure activity.
- B. Assure the parents that the frequency of febrile seizures decreases as the child ages.
- C. Suggest giving the child a sponge bath when the temperature exceeds 100.6°F (38.1°C).
- D. Advise the prophylactic use of Ibuprofen to prevent febrile seizures.
Correct Answer: B
Rationale: Febrile seizures typically decrease with age, often resolving by age 5.
A newborn with a repaired gastroschisis is transferred to the pediatric unit after several days in the pediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Speak to the healthcare provider about instituting physical therapy.
- B. Offer a pacifier for non-nutritive sucking.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Use sterile technique during feedings.
Correct Answer: B
Rationale: Offering a pacifier for non-nutritive sucking promotes oral feeding skills and emotional stability, supporting normal growth and development in infants with gastroschisis repair.
A 1-year-old child with respiratory syncytial virus (RSV) is admitted to the pediatric unit. The child presents with a fever, rhinorrhea, frequent coughing, and sneezing. What additional finding should alert the nurse that the child is in acute respiratory distress?
- A. Diaphragmatic respirations.
- B. A resting respiratory rate of 35 breaths/min.
- C. Bilateral bronchial breath sounds.
- D. Flaring of the nares.
Correct Answer: D
Rationale: Nasal flaring indicates increased breathing effort, a sign of acute respiratory distress in RSV.
A 5-week-old infant who has been experiencing projectile vomiting after feedings. What additional symptom should the nurse anticipate?
- A. Stool containing mucus and blood.
- B. An olive-sized mass in the epigastric region.
- C. Frequent burping accompanied by poor feeding.
- D. Rebound tenderness in the left lower abdominal quadrant.
Correct Answer: B
Rationale: An olive-sized mass suggests pyloric stenosis, a common cause of projectile vomiting.