What should nursing interventions to maintain a patent airway in a newborn include?

Correct Answer: D

Rationale: Nursing interventions to maintain a patent airway in a newborn should prioritize safety and best practices. Positioning the neonate supine while sleeping is crucial to reduce the risk of sudden infant death syndrome (SIDS) and ensure proper airway alignment. Using a bulb syringe to suction as needed, with the correct technique of suctioning the nose first and then the pharynx, helps effectively remove secretions and keep the airway clear. This intervention promotes optimal respiratory function and reduces the risk of airway obstruction in newborns. Sleeping in the prone position is not recommended due to the increased risk of SIDS. Wrapping the neonate as snugly as possible can also pose risks of overheating and compromising the airway, making it an unsafe practice.

Correct Answer: C

Rationale: The nurse would first assess for an irregular heart rate and rhythm. In a 4-month old infant with a congenital heart defect experiencing marked dyspnea at rest, the sudden onset of cyanosis (blue coloration) and increased respiratory rate can indicate worsening heart failure and potential arrhythmias. Assessing for any abnormal heart rhythms is a priority to determine if immediate intervention is required to stabilize the infant's condition and prevent further deterioration.

Correct Answer: D

Rationale: Tachycardia, which is an abnormally fast heart rate, is a common sign of digoxin toxicity. Digoxin has a narrow therapeutic index, meaning there is a narrow range between a therapeutic dose and a toxic dose. Symptoms of digoxin toxicity can manifest in the cardiovascular system, such as tachycardia, as well as in other systems of the body. Tachycardia is often seen in cases of digoxin toxicity due to its effects on the heart's electrical conduction system. Other common signs of digoxin toxicity include nausea, vomiting, blurred vision, confusion, and arrhythmias. It is crucial for healthcare providers to monitor patients receiving digoxin closely and educate them about the signs and symptoms of toxicity to prevent adverse outcomes.

Correct Answer: C

Rationale: Binocularity refers to the ability of both eyes to focus on the same object and create a single, three-dimensional image. In infants, binocularity typically develops between the ages of 6 to 8 months. Prior to this age, it is common for infants to show occasional misalignment or "crossed" eyes when focusing on an object. This is usually a normal part of the visual development process and tends to resolve as binocular vision strengthens with age. Therefore, it is considered normal for newborns to show occasional crossed eyes until binocularity develops around 6 to 8 months of age.

Correct Answer: C

Rationale: Activated charcoal can help reduce absorption of acetaminophen, and plasma levels should be measured 4 hours post-ingestion to assess toxicity using the nomogram.