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1. An infant who underwent a cardiac surgery has a chest tube inserted to
drain blood and fluid from the mediastinum. What is the normal amount
of drainage expected in the first 24 hours after surgery?
A) 10-20 ml/kg
B) 20-30 ml/kg
C) 30-40 ml/kg
D) 40-50 ml/kg
Answer: B) 20-30 ml/kg
Rationale: The normal amount of drainage in the first 24 hours after
cardiac surgery is 20-30 ml/kg. More than this may indicate excessive
bleeding or fluid accumulation, while less than this may indicate
obstruction or clotting of the chest tube.
2. An infant who underwent a cleft lip repair has a Logan bow applied to
protect the suture line and reduce tension. What is the appropriate nursing
intervention to prevent skin breakdown and infection at the site of the
Logan bow?
A) Apply petroleum jelly to the skin under the bow
B) Clean the skin under the bow with saline solution
C) Change the bow every 4 hours
D) Cover the bow with sterile gauze
Answer: A) Apply petroleum jelly to the skin under the bow
Rationale: Applying petroleum jelly to the skin under the Logan bow
helps to prevent skin irritation and breakdown from friction and moisture.
Cleaning the skin with saline solution may cause drying and cracking,
changing the bow too frequently may disrupt healing, and covering the
bow with gauze may interfere with its function.
3. An infant who underwent a pyloromyotomy for hypertrophic pyloric
stenosis has resumed oral feeding after surgery. What is the best indicator
that the infant is tolerating the feedings well?
A) The infant has no vomiting or regurgitation
B) The infant has normal bowel sounds and stools
C) The infant has a weight gain of 10 g/day
D) The infant has a decrease in abdominal distension
Answer: A) The infant has no vomiting or regurgitation
Rationale: The main symptom of hypertrophic pyloric stenosis is
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