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 C
Explanation
Choice A rationale
The conjunctivae, the mucous membranes that cover the front of the eye and line the inside of the eyelids, can show signs of cyanosis. However, they are not the most reliable indicator of central cyanosis. Central cyanosis is best observed in areas with a rich blood supply and thin skin, where the bluish discoloration due to low oxygen levels in the blood is more apparent.
Choice B rationale
The soles of the feet are not a reliable indicator of central cyanosis. Peripheral cyanosis, which affects the extremities, can occur due to poor circulation or cold temperatures and does not necessarily indicate central cyanosis. Central cyanosis is more accurately assessed in areas with a high concentration of blood vessels and thin skin.
Choice C rationale
The oral mucosa, including the lips and tongue, is the most reliable indicator of central cyanosis. This area has a rich blood supply and thin skin, making it easier to observe the bluish discoloration caused by low oxygen levels in the blood. Central cyanosis is a sign of significant hypoxemia and requires prompt medical attention.
Choice D rationale
The ear lobes are not the most reliable indicator of central cyanosis. While they can show signs of cyanosis, they are not as accurate as the oral mucosa. The ear lobes may be affected by peripheral cyanosis, which can occur due to factors like cold temperatures or poor circulation, rather than central cyanosis.
Correct Answer is B
Explanation
Choice A rationale
Obtaining a throat culture is contraindicated in suspected epiglottitis. This procedure can cause further irritation and potentially lead to airway obstruction. Epiglottitis is a medical emergency, and the priority is to maintain a patent airway.
Choice B rationale
Placing the child in an upright position is the correct action. This position helps improve breathing and reduces the risk of airway obstruction. It also allows for better visualization and assessment of the child’s respiratory status.
Choice C rationale
Visualizing the epiglottis with a tongue depressor is not recommended in suspected epiglottitis. This action can cause further irritation and potentially lead to airway obstruction. The priority is to maintain a patent airway and avoid any procedures that could exacerbate the condition.
Choice D rationale
Transporting the child to radiology for a throat x-ray is not the immediate priority. While imaging may be necessary for diagnosis, the primary focus should be on maintaining a patent airway and ensuring the child’s respiratory status is stable.