A nurse is assessing a toddler who has a history of lead poisoning. Which of the following actions should the nurse take?
Perform developmental testing for delays.
Initiate a low-iron diet for lead absorption.
Obtain a stool specimen for lead levels.
Inspect the skin for discoloration.
The Correct Answer is A
A. Toddlers with a history of lead poisoning are at risk for developmental delays.
Developmental testing can help identify any delays that may require intervention or support.
B. Lead absorption is not related to iron intake. However, a diet rich in iron can help reduce the absorption of lead.
C. Blood testing, not stool testing, is the primary method for assessing lead levels. Blood lead levels provide the most accurate information about lead exposure.
D. While lead poisoning can cause changes in skin color in severe cases, it is not the primary assessment for lead exposure. Blood lead levels and developmental testing are more indicative of lead poisoning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct action. Offering a pacifier coated with an oral sucrose solution before the injections can provide comfort and help alleviate pain associated with the immunizations.
B. Administering immunizations into the deltoid muscle is not recommended for infants.
For young infants, immunizations are typically given in the anterolateral thigh muscle.
C. Using a 20-gauge needle is not recommended for infants, as it is a larger gauge and may cause more discomfort. A smaller gauge needle is typically used for infant
immunizations.
D. Applying an eutectic mixture of local anesthetics (EMLA) cream immediately before the injections is not a standard practice for routine infant immunizations. It may not be necessary for most infants and could increase the overall time and complexity of the procedure.
Correct Answer is D
Explanation
A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.
B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
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