1. 1. Question
While assessing a one-month-old infant, which of the findings warrants further investigation by the nurse? Select all that apply.
o A.
... [Show More] Abdominal respirations
o B. Irregular breathing rate
o C. Inspiratory grunt
o D. Increased heart rate with crying
o E. Nasal flaring
o F. Cyanosis
o G. Asymmetric chest movement
Correct Answers: C, E, F, & G
o Option C. Grunting occurs when an infant attempts to maintain an adequate functional residual capacity in the face of poorly compliant lungs by partial glottic closure. As the infant prolongs the expiratory phase against this partially closed glottis, there is a prolonged and increased residual volume that maintains the airway opening and also an audible expiratory sound.
o Option E: Nasal flaring occurs when the nostrils widen while breathing and is a sign of troubled breathing or respiratory distress.
o Option F: Cyanosis refers to the bluish discoloration of the skin and indicates a decrease in oxygen attached to the red blood cells in the bloodstream.
o Option G: Asymmetric chest movement occurs when the abnormal side of the lungs expands less and lags behind the normal side. This indicates respiratory distress.
o Option A: Abdominal respiration is normal among infants and young children. Since their intercostal muscles are not yet fully developed, they use their abdominal muscles much more to pull the diaphragm down for breathing.
o Option B: Newborns can have irregular breathing patterns ranging from 30 to 60 breaths per minute with short periods of apnea (15 seconds).
o Option D: An increase in heart rate is normal for an infant during activity (including crying). Fluctuations in heart rate follow the changes in the newborn’s behavioral state – crying, movement, or wakefulness corresponds to an increase in heart rate.
2. 2. Question
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the order in which the nurse must carry out the following actions prior to the administration of preoperative medications.
View Answers:
o Place the call bell within reach
o Raise the side rails on the bed
o Have the client empty bladder
o Instruct the client to remain in bed
Correct order is shown above.
o Have the client empty the bladder. The first step in the process is to have the client void prior to administering the pre-operative medication. If the client does not have a catheter, it is important to empty the bladder before receiving preoperative medications to prevent bladder injury (especially in pelvic surgeries). Else, a straight catheter or an indwelling catheter may be ordered to ensure the bladder is empty.
o Instruct the client to remain in bed. Preoperative medications can cause drowsiness and lightheadedness which may put the client at risk for injury.
o Raise the side rails on the bed. Raising the side rails on the bed helps prevent accidental falls and injury when the client decides to get out of the bed without assistance.
o Place the call bell within reach. Call bells should always be within the reach of a client. [Show Less]