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. Withhold opioids to avoid dependence.

This option is incorrect. Opioid analgesics are commonly used to manage the severe pain associated with sickle cell crisis. Withholding opioids during a crisis could lead to inadequate pain relief and compromise the adolescent's comfort and recovery. It's important to appropriately administer opioids as prescribed to alleviate pain and suffering.

B. Assist RN with administering a blood transfusion.

This option may be appropriate depending on the severity and indications of the sickle cell crisis. Blood transfusions are sometimes used to treat sickle cell crises, particularly in cases of severe anemia or acute complications such as acute chest syndrome. However, the decision to administer a blood transfusion should be made by the healthcare provider based on the individual patient's clinical status and needs. The nurse's role would include assisting the registered nurse (RN) with the administration of the transfusion and monitoring the adolescent for any adverse reactions.

C. Initiate a 2 L/day fluid restriction.

This option is incorrect. During a sickle cell crisis, it is important to maintain adequate hydration to help prevent dehydration and reduce the viscosity of blood, which can help prevent sickling of red blood cells. Fluid intake should be encouraged, and there is typically no need for fluid restriction unless there are specific medical reasons to do so.

D. Encourage exercise.

This option is incorrect. During a sickle cell crisis, the adolescent is likely experiencing significant pain and discomfort, which may limit their ability to engage in physical activity. Encouraging exercise during a crisis could exacerbate pain and potentially lead to complications. Rest and minimizing physical exertion are typically recommended during a sickle cell crisis to promote comfort and conserve energy.