A nurse is collecting data about an IV infusion site on an infant’s left hand.
Which of the following findings should the nurse identify as an indication of an infiltration?
Edema in the palm of the hand.
Absence of blanching at the insertion site.
Warmth around the insertion site.
Blood in the IV tubing.
The Correct Answer is A
Choice A rationale
Edema in the palm of the hand is a sign of IV infiltration. IV infiltration occurs when IV fluids or medications leak into the surrounding tissues outside the intended vein. This can cause swelling or edema, which is a common sign of infiltration.
Choice B rationale
Absence of blanching at the insertion site is not necessarily an indication of an infiltration. Blanching (whitening of the skin) can occur due to various reasons, including pressure on the site or a reaction to the IV fluid or medication. However, it is not a definitive sign of infiltration.
Choice C rationale
Warmth around the insertion site is not a definitive sign of an infiltration. While warmth can occur due to inflammation or infection, it is not a specific sign of infiltration.
Choice D rationale
Blood in the IV tubing is not a definitive sign of an infiltration. While blood can back up into the IV tubing due to various reasons, including a blocked or kinked catheter, it is not a specific sign of infiltration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While some babies may experience rapid growth and double their birth weight within the first 3 months, this is not typically expected. Most infants are expected to double their birth weight by 5 to 6 months of age.
Choice B rationale
Most infants are expected to double their birth weight by 5 to 6 months of age. Therefore, by the age of 6 months, it would be expected for an infant to have doubled their birth weight.
Choice C rationale
By 9 months, most infants would have already doubled their birth weight. The typical expectation is for infants to double their birth weight by 5 to 6 months of age.
Choice D rationale
By 12 months, most infants would have already doubled their birth weight and are on their way to tripling their birth weight. Therefore, expecting an infant to double their birth weight by 12 months would be beyond the typical timeframe.
Correct Answer is D
Explanation
Choice A rationale
At 10 months, it is normal for an infant to not be able to recognize objects by name. Language development varies greatly among children, and many do not start to understand and respond to simple requests and recognize common objects until around 12 months.
Choice B rationale
The ability to turn pages in a book is a fine motor skill that typically develops around 12 to 18 months. Therefore, it is normal for a 10-month-old infant to not have this ability.
Choice C rationale
Peek-a-boo is a common game that many infants enjoy. However, not all infants may show interest in this game. Lack of interest in peek-a-boo is not necessarily a cause for concern.
Choice D rationale
By 10 months, most infants can sit without support. If a 10-month-old infant does not sit steadily without support, it could indicate a delay in motor development and should be reported to the provider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.