A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?

A. "I will elevate the affected area if possible."

This statement is correct. Elevating the affected area can help reduce swelling and minimize bleeding by promoting venous return. Elevating the limb above the level of the heart can aid in controlling bleeding and is a recommended intervention.

B. "I will apply warm compresses over the site."

This statement is incorrect. Applying warm compresses is generally not recommended for controlling bleeding in hemophilia. Heat can increase blood flow to the area, potentially exacerbating bleeding. Cold compresses or ice packs are typically recommended to help constrict blood vessels and reduce bleeding.

C. "I will have my child rest."

This statement is correct. Resting is an essential component of managing bleeding episodes in children with hemophilia. Physical activity and exertion can increase the risk of injury and bleeding, so it's important for children with hemophilia to avoid strenuous activities during bleeding episodes.

D. "I will promptly mobilize the involved area to relieve pain & decrease bleeding."

Immobilizing the affected area can help control bleeding and reduce pain by minimizing movement. This is also an appropriate response.

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.