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The nurse is planning care for an infant who has a diagnosis of hypertrophic pyloric stenosis and is scheduled for surgery. Which intervention should the nurse include to meet the infant's preoperative needs?
- A. Administer enemas until returns are clear.
- B. Provide the mother privacy to breast-feed every 2 hours.
- C. Monitor the intravenous (IV) infusion, intake, output, and weight.
- D. Provide small, frequent feedings of glucose, water, and electrolytes.
Correct Answer: C
Rationale: Preoperatively, important nursing responsibilities for the child with hypertrophic pyloric stenosis include monitoring the IV infusion, intake, output, and weight and obtaining urine specific gravity measurements. Additionally, weighing the infant's diapers provides information regarding output. Enemas until clear would further compromise the fluid volume status. Preoperatively, the infant receives nothing by mouth unless otherwise prescribed by the primary health care provider.
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The nurse is preparing to admit a client from the postanesthesia care unit who has had microvascular decompression of the trigeminal nerve. Which equipment should the nurse ask the unlicensed assistive personnel to make sure is at the bedside when the client arrives?
- A. Flashlight and pulse oximeter
- B. Cardiac monitor and suction equipment
- C. Padded bed rails and suction equipment
- D. Blood pressure cuff and cardiac monitor
Correct Answer: A
Rationale: The postoperative care of the client having microvascular decompression of the trigeminal nerve is the same as for the client undergoing craniotomy. This client requires hourly neurological assessment as well as monitoring of the cardiovascular and respiratory statuses. Therefore, a flashlight and pulse oximetry are necessary items. Cardiac monitoring and padded bed rails are not indicated unless there is a special need based on a client history of cardiac disease or seizures, respectively. Suctioning is performed cautiously and only when necessary after craniotomy to avoid increasing the intracranial pressure.
The nurse preparing to admit a 7-month-old infant with febrile seizures should anticipate the need for which equipment when planning care for this infant?
- A. Restraints at the bedside
- B. A code cart at the bedside
- C. Suction equipment and an airway at the bedside
- D. A padded tongue blade taped to the head of the bed
Correct Answer: C
Rationale: Suctioning may be required during a seizure to remove secretions that obstruct the airway. An airway should also be readily available. During a seizure, the infant should be placed in a side-lying position, but should not be restrained. It is not necessary to place a code cart at the bedside, but a cart should be readily available on the nursing unit. A padded tongue blade should never be used; in fact, nothing should be placed in the mouth during a seizure.
The nurse is caring for a hospitalized child with a diagnosis of rheumatic fever who has developed carditis. The mother asks the nurse to explain the meaning of carditis. On which description of this complication of rheumatic fever should the nurse base a response?
- A. Involuntary movements affecting the legs, arms, and face
- B. Inflammation of all parts of the heart, primarily the mitral valve
- C. Tender, painful joints, especially in the elbows, knees, ankles, and wrists
- D. Red skin lesions that start as flat or slightly raised macules, usually over the trunk, and that spread peripherally
Correct Answer: B
Rationale: Carditis is the inflammation of all parts of the heart, primarily the mitral valve, and it is a complication of rheumatic fever. Option 1 describes chorea. Option 3 describes polyarthritis. Option 4 describes erythema marginatum.
A 10-month-old infant is hospitalized for respiratory syncytial virus (RSV). On the basis of the developmental stage of the infant, what intervention should the nurse include in the plan of care?
- A. Restrain the infant with a total body restraint to prevent any tubes from being dislodged.
- B. Follow the home feeding schedule, and allow the infant to be held only when the parents visit.
- C. Wash hands, wear a mask when caring for the infant, and keep the infant as quiet as possible.
- D. Provide a consistent routine, and touch, rock, and cuddle the infant throughout the hospitalization.
Correct Answer: D
Rationale: A 10-month-old infant is in the trust versus mistrust stage of psychosocial development, according to Erik Erikson, and the sensorimotor period of cognitive development, according to Jean Piaget. Hospitalization may have an adverse effect. A consistent routine accompanied by touching, rocking, and cuddling will help the child develop trust and provide sensory stimulation. Total body restraint is unnecessary and an incorrect action. Touching and holding the infant only when the parents visit will not provide adequate stimulation and interpersonal contact for the infant. RSV is not airborne (a mask is not required), and it is usually transmitted by the hands.
The nurse is preparing to assist in the administration of a chemotherapeutic agent via intraperitoneal (IP) therapy. In which position should the nurse plan to place the client before administering this therapy?
- A. Supine
- B. Semi-Fowler's
- C. Trendelenburg's
- D. Dorsal recumbent
Correct Answer: B
Rationale: IP therapy is the administration of chemotherapeutic agents into the peritoneal cavity. This therapy is used for intra-abdominal malignancies such as ovarian and gastrointestinal tumors that have moved into the peritoneum after surgery. The client should be placed in a semi-Fowler's position for this infusion because the client may experience nausea and vomiting caused by increasing pressure on the internal organs. Additionally, this treatment may also place pressure on the diaphragm. The positions indicated in the rest of the options would increase pressure in the peritoneal cavity.