A nurse is presenting an in-service about the use of postural drainage for infants who have cystic fibrosis. Which of the following positions should the nurse identify as being contraindicated for the infant?
Sitting on a nurse’s lap leaning forward.
Supine.
Sitting on a nurse’s lap leaning backward.
Trendelenburg.
The Correct Answer is D
Choice A rationale
Sitting on a nurse’s lap leaning forward is a position that can be used for postural drainage in infants with cystic fibrosis. This position helps drain secretions from the upper lobes of the lungs.
Choice B rationale
The supine position (lying on the back) is also used for postural drainage to target different areas of the lungs. It is not contraindicated for infants with cystic fibrosis.
Choice C rationale
Sitting on a nurse’s lap leaning backward is another position that can be used for postural drainage. This position helps drain secretions from the lower lobes of the lungs.
Choice D rationale
The Trendelenburg position (lying flat on the back with the feet elevated higher than the head) is contraindicated for infants with cystic fibrosis. This position can increase the risk of gastroesophageal reflux and aspiration, which can worsen respiratory symptoms.
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Correct Answer is A
Explanation
ChoiceA rationale
Theapexoftheheart(apicalpulse)isthepreferredsiteforassessingtheheartrateininfants.It is located at the point of maximal impulse (PMI) and provides the most accuratemeasurementof theheartrateinthisagegroup.
ChoiceB rationale
The brachial artery is not the preferred site for assessing the heart rate in infants. While it canbeused forbloodpressuremeasurement,itisnotasaccurateastheapicalpulseforheartrateassessment.
ChoiceCrationale
Theradialarteryisnottypicallyusedforassessingthe heartrateininfants.Itismorecommonlyusedinolderchildren andadults.
ChoiceD rationale
Thecarotidarteryisnotrecommendedforassessingtheheartrateininfantsduetotheriskofcompressingtheairwayandcausingdiscomfort.
Correct Answer is C
Explanation
Choice A rationale
Placing the child on a no-salt-added diet is important for managing fluid retention and hypertension in acute glomerulonephritis, but it is not the immediate priority.
Choice B rationale
Educating the parents about potential complications is essential for long-term management, but it is not the immediate priority in an acute setting.
Choice C rationale
Checking the child’s daily weight is the priority action because it helps monitor fluid balance and detect any signs of fluid retention or worsening condition. Accurate daily weight measurements are crucial for assessing the effectiveness of treatment and making necessary adjustments.
Choice D rationale
Maintaining a saline-lock is important for intravenous access, but it is not the immediate priority compared to monitoring fluid balance through daily weight checks.