A 6-month-old infant with Apical heart rate of 60.
congestive heart failure (CHF) is
receiving digoxin elixir. Which A heart rate of 60 (A) is much lower than normal for a 6-month-old
observation by the nurse and warrants immediate intervention. The normal heart rate for a 6-
warrants immediate intervention? month-old is 80 to 150 BPM when awake, and a rate of 70 while
Apical heart rate of 60. sleeping is considered within normal limits. (B and C) are expected
Sweating across the forehead. symptoms of heart failure in an infant. (D) is within normal limits for
Doesn't suck well. an infant.
Respiratory rate of 30 breaths per
minute.
The nurse is teaching the parents Administer aerosol therapy followed by postural drainage before
of a 5-year-old with cystic meals.
fibrosis about respiratory
treatments. Which statement Postural drainage for a child with cystic fibrosis is most effective
indicates to the nurse that the when performed after nebulization and before meals (C) or at
parents understand? least 1 hour after eating to prevent nausea and vomiting. Postural
Perform postural drainage before drainage uses gravity to promote mucous removal after
starting aerosol therapy. nebulization (A) treatments which open the airways. Pulmonary
Give respiratory treatments when toileting or respiratory treatments should be given 3 to 4 times
the child is coughing a lot. daily, not episodically (B and D).
Administer aerosol therapy
followed by postural drainage
before meals.
Ensure respiratory therapy is
done daily during any respiratory
infection.
,A female teenager is taking oral Use sunscreen when lying by the pool.
tetracycline HCL (Achromycin V)
for acne vulgaris. What is the Photosensitivity is a common side effect of tetracycline HCL
most important instruction for the (Achromycin V) therapy. Severe sunburn can occur with minimal
nurse to include in this client's sun exposure and clients should be instructed to avoid sunlight
teaching plan? and to use sunscreen (A). (B and D) are not related to tetracycline
Use sunscreen when lying by the HCL (Achromycin V) therapy. (C) should be avoided because dairy
pool. products interfere with the absorption of tetracyclines.
Cleanse the skin at least 4 times a
day.
Take the medication with a glass
of milk.
Menstrual periods may become
irregular.
What preoperative nursing Observe for projectile vomiting.
intervention should be included
in the plan of care for an infant Projectile vomiting (D), which contributes to metabolic alkalosis
with pyloric stenosis? (A), is the classic sign of pyloric stenosis. (B) is not indicated. (C) is
Monitor for signs of metabolic dangerous, due to the potential for aspiration with frequent
acidosis. vomiting.
Estimate the quantity of diarrhea
stools.
Place in a supine position after
feeding.
Observe for projectile vomiting.
,An infant is born with a Prevent the return of oxygenated blood to the lungs.
ventricular septal defect (VSD)
and surgery is planned to correct Closure of VSDs stops oxygenated blood from being shunted
the defect. The nurse recognizes from the left ventricle to the right ventricle (C). VSDs are acyanotic
that surgical correction is defects, which means that no unoxygenated blood enters the
designed to achieve which systemic circulation (A and B). (D) is common with Tetrology of
outcome? Fallot, which is a cyanotic defect.
Stop the flow of unoxygenated
blood into systemic circulation.
Increase the flow of
unoxygenated blood to the
lungs.
Prevent the return of oxygenated
blood to the lungs.
Reduce peripheral tissue hypoxia
and nailbed clubbing
, A 3-week-old newborn is A. Monitor the the infant's weight and number of wet diapers per
brought to the clinic for follow- day.
up after a home birth. The mother B. Increase the infant's intake per feeding by 1 to 2 ounces per
reports that her child bottle week.
feeds for 5 minutes only and then D. Allow the infant to rest and refeed on demand or every 2 hours.
falls asleep. The nurse auscultates E. Use a softer nipple or increase the size of the nipple opening.
a loud murmur characteristic of a
ventricular septal defect (VSD), Antibiotic prophylaxis is recommended for infants with VSDs, but
and finds the newborn is should not be mixed in a bottle of formula (C) because it is difficult
acyanotic with a respiratory rate to ensure that the total dose is consumed.
of 64 breaths per minute. What
instruction should the nurse They should be monitored for weight gain and at least 6 wet
provide the mother to ensure the diapers per day (A). A one-month old infant should ingest 2 to 4
infant is receiving adequate ounces of formula per feeding and progress to about 30 ounces
intake? (Select all that apply.) per day by 4-months of age (B)
A. Monitor the the infant's weight
and number of wet diapers per
day.
B. Increase the infant's intake per
feeding by 1 to 2 ounces per
week.
C. Mix the dose of prophylactic
antibiotic in a full bottle of
formula.
D. Allow the infant to rest and
refeed on demand or every 2
hours.
E. Use a softer nipple or increase
the size of the nipple opening.
congestive heart failure (CHF) is
receiving digoxin elixir. Which A heart rate of 60 (A) is much lower than normal for a 6-month-old
observation by the nurse and warrants immediate intervention. The normal heart rate for a 6-
warrants immediate intervention? month-old is 80 to 150 BPM when awake, and a rate of 70 while
Apical heart rate of 60. sleeping is considered within normal limits. (B and C) are expected
Sweating across the forehead. symptoms of heart failure in an infant. (D) is within normal limits for
Doesn't suck well. an infant.
Respiratory rate of 30 breaths per
minute.
The nurse is teaching the parents Administer aerosol therapy followed by postural drainage before
of a 5-year-old with cystic meals.
fibrosis about respiratory
treatments. Which statement Postural drainage for a child with cystic fibrosis is most effective
indicates to the nurse that the when performed after nebulization and before meals (C) or at
parents understand? least 1 hour after eating to prevent nausea and vomiting. Postural
Perform postural drainage before drainage uses gravity to promote mucous removal after
starting aerosol therapy. nebulization (A) treatments which open the airways. Pulmonary
Give respiratory treatments when toileting or respiratory treatments should be given 3 to 4 times
the child is coughing a lot. daily, not episodically (B and D).
Administer aerosol therapy
followed by postural drainage
before meals.
Ensure respiratory therapy is
done daily during any respiratory
infection.
,A female teenager is taking oral Use sunscreen when lying by the pool.
tetracycline HCL (Achromycin V)
for acne vulgaris. What is the Photosensitivity is a common side effect of tetracycline HCL
most important instruction for the (Achromycin V) therapy. Severe sunburn can occur with minimal
nurse to include in this client's sun exposure and clients should be instructed to avoid sunlight
teaching plan? and to use sunscreen (A). (B and D) are not related to tetracycline
Use sunscreen when lying by the HCL (Achromycin V) therapy. (C) should be avoided because dairy
pool. products interfere with the absorption of tetracyclines.
Cleanse the skin at least 4 times a
day.
Take the medication with a glass
of milk.
Menstrual periods may become
irregular.
What preoperative nursing Observe for projectile vomiting.
intervention should be included
in the plan of care for an infant Projectile vomiting (D), which contributes to metabolic alkalosis
with pyloric stenosis? (A), is the classic sign of pyloric stenosis. (B) is not indicated. (C) is
Monitor for signs of metabolic dangerous, due to the potential for aspiration with frequent
acidosis. vomiting.
Estimate the quantity of diarrhea
stools.
Place in a supine position after
feeding.
Observe for projectile vomiting.
,An infant is born with a Prevent the return of oxygenated blood to the lungs.
ventricular septal defect (VSD)
and surgery is planned to correct Closure of VSDs stops oxygenated blood from being shunted
the defect. The nurse recognizes from the left ventricle to the right ventricle (C). VSDs are acyanotic
that surgical correction is defects, which means that no unoxygenated blood enters the
designed to achieve which systemic circulation (A and B). (D) is common with Tetrology of
outcome? Fallot, which is a cyanotic defect.
Stop the flow of unoxygenated
blood into systemic circulation.
Increase the flow of
unoxygenated blood to the
lungs.
Prevent the return of oxygenated
blood to the lungs.
Reduce peripheral tissue hypoxia
and nailbed clubbing
, A 3-week-old newborn is A. Monitor the the infant's weight and number of wet diapers per
brought to the clinic for follow- day.
up after a home birth. The mother B. Increase the infant's intake per feeding by 1 to 2 ounces per
reports that her child bottle week.
feeds for 5 minutes only and then D. Allow the infant to rest and refeed on demand or every 2 hours.
falls asleep. The nurse auscultates E. Use a softer nipple or increase the size of the nipple opening.
a loud murmur characteristic of a
ventricular septal defect (VSD), Antibiotic prophylaxis is recommended for infants with VSDs, but
and finds the newborn is should not be mixed in a bottle of formula (C) because it is difficult
acyanotic with a respiratory rate to ensure that the total dose is consumed.
of 64 breaths per minute. What
instruction should the nurse They should be monitored for weight gain and at least 6 wet
provide the mother to ensure the diapers per day (A). A one-month old infant should ingest 2 to 4
infant is receiving adequate ounces of formula per feeding and progress to about 30 ounces
intake? (Select all that apply.) per day by 4-months of age (B)
A. Monitor the the infant's weight
and number of wet diapers per
day.
B. Increase the infant's intake per
feeding by 1 to 2 ounces per
week.
C. Mix the dose of prophylactic
antibiotic in a full bottle of
formula.
D. Allow the infant to rest and
refeed on demand or every 2
hours.
E. Use a softer nipple or increase
the size of the nipple opening.
