A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?

A. Measure the elixir in a medicine cup before transferring to a syringe:

This option involves measuring the medication using a medicine cup before transferring it to an oral medication syringe. While measuring the medication accurately is important, transferring it from a medicine cup to a syringe introduces an extra step that may increase the risk of spillage or dosage error. It's generally more efficient and accurate to directly draw the medication into the oral syringe.

B. Place the infant supine in a crib prior to administration:

Placing the infant in a supine (lying flat on the back) position in a crib prior to administering oral medication is not recommended, particularly for infants of this age. This position increases the risk of choking or aspiration, as it may cause the medication to flow toward the back of the throat rather than being swallowed properly. It's safer to administer oral medication to infants in an upright or slightly reclined position.

C. Position the syringe to the side of the infant's tongue:

This is the correct choice. Positioning the syringe to the side of the infant's tongue helps facilitate swallowing and reduces the risk of choking or aspiration. Placing the syringe toward the cheek allows the infant to more easily swallow the medication, as it minimizes the chance of the medication flowing toward the back of the throat.

D. Mix the medication with 10 mL of formula:

Mixing medication with formula is not a standard practice for administering oral medication using an oral syringe, particularly without specific instructions from the healthcare provider. Mixing medication with formula may alter the medication's effectiveness and is unnecessary for most oral medications. It's important to administer oral medication directly using an oral syringe to ensure accurate dosing and effectiveness.

A. Allow the child to see and touch IV tubing and supplies.

Allowing the child to see and touch the IV tubing and supplies can help familiarize them with the equipment and reduce anxiety. However, there may be a more appropriate action to take first.

B. Explain to the child's parents what role they will have during the procedure.

While it's important to involve the child's parents and inform them of their role during the procedure, the priority should be to prepare the child for the insertion itself.

C. Describe the procedure using visual aids.

Using visual aids can be helpful in explaining the procedure to the child and providing a clear understanding of what will happen. However, there may be a more appropriate action to take first.

D. Ask the child what he knows about the procedure.

This is the correct answer. Asking the child what they already know about the procedure allows the nurse to assess their understanding and address any misconceptions or concerns they may have. It also helps the nurse tailor their explanation to the child's level of understanding and provide information that is relevant and meaningful to them.