157. When should a newborn be assessed for a T/E defect?
a. Before the first feeding
b. After the first cry
c. As soon as meconium is passed
d. As soon as body temperature is stable
158. How should the nurse interpret the assessment finding that a client with bronchiectasis expectorated three cupfuls of foul-smelling mucopurulent secretions in the last 24 hours?
a. A secondary infection has developed.
b. The disease process is resolving.
c. Client is exhibiting usual symptoms of the disease
d. Chest physical therapy needs to be adjusted to client’s need.
157. Correct answer: a.
Assessment for T/E defect should be done immediately after birth and before the first feeding. Usually, sterile water is given first since the infant may swallow normally but suddenly coughs and struggles and fluid is aspirated or returned through the nose and mouth. Presence of frothy saliva in the mouth, difficulty handling secretions, or periods of unexplained cyanosis require that an infant be referred immediately for medical evaluation for T/E defect.
158. Correct answer: c.
Bronchiectasis is characterized by a chronic cough with production of several cupfuls of foul-smelling mucopurulent sputum per day. Production of large amounts of this type of sputum does not indicate suprainfection, disease resolution or that chest physical therapy needs to be changed.