A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care?
Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure.
Keep the infant NPO for 6 hr prior to the procedure.
Hold the infant's chin to his chest and knees to his abdomen during the procedure.
Place the infant in an infant seat for 2 hr following the procedure.
The Correct Answer is C
The correct answer is: c. Hold the infant’s chin to his chest and knees to his abdomen during the procedure.
Choice A: Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure.
Applying a eutectic mixture of lidocaine and prilocaine (EMLA) cream can help reduce pain during procedures like lumbar punctures. However, it typically needs to be applied 30 to 60 minutes before the procedure to be effective. Applying it only 15 minutes prior would not provide adequate analgesia.
Choice B: Keep the infant NPO for 6 hr prior to the procedure.
Keeping an infant NPO (nothing by mouth) for 6 hours is generally recommended before procedures requiring sedation or anesthesia to reduce the risk of aspiration. However, lumbar punctures do not typically require such prolonged fasting, especially in infants, unless sedation is planned.
Choice C: Hold the infant’s chin to his chest and knees to his abdomen during the procedure.
This is the correct positioning for a lumbar puncture in infants. The infant should be held in a curled-up position, with the chin to the chest and knees to the abdomen, to maximize the space between the vertebrae and allow easier access to the lumbar region. This position helps to stabilize the infant and reduce movement during the procedure.
Choice D: Place the infant in an infant seat for 2 hr following the procedure.
Post-procedure care for a lumbar puncture typically involves monitoring the infant for any signs of complications, such as headache or infection. Placing the infant in an infant seat for 2 hours is not a standard recommendation. Instead, the infant should be observed and allowed to rest comfortably.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: The OUCHER scale is not suitable for a 2-month-old infant, as it is designed for children aged 3 to 13 years who can point to pictures of faces that match their pain level. A 2-month-old infant cannot communicate verbally or point to pictures.
Choice B: The FACES scale is not suitable for a 2-month-old infant, as it is designed for children aged 3 years and older who can select a face that matches their pain level. A 2-month-old infant cannot communicate verbally or select a face.
Choice C: The PAINAD scale is not suitable for a 2-month-old infant, as it is designed for adults who have advanced dementia and cannot verbalize their pain. A 2-month-old infant does not have dementia and may have different behavioral indicators of pain.
Choice D: The FLACC scale is suitable for a 2-month-old infant, as it is designed for infants and children aged 2 months to 7 years who cannot verbalize their pain. The FLACC scale assesses five behavioral indicators of pain: face, legs, activity, cry, and consolability. Each indicator is scored from 0 to 2 based on the observation of the nurse. The total score ranges from 0 to 10, with higher scores indicating more pain.
Correct Answer is C
Explanation
Choice A: A popping sensation when swallowing is not a sign of a tympanic membrane rupture, as it is a normal phenomenon that occurs when the eustachian tube opens and closes to equalize the pressure between the middle ear and the atmosphere. A popping sensation when swallowing may be associated with otitis media with effusion, which is a condition that causes fluid accumulation behind the eardrum, but it does not indicate a rupture.
Choice B: Green-blue discharge could be indicative of infection but is not as directly related to the rupture event as the sudden pain relief is.
Choice C: The correct answer is sudden relief of pain. This is because the rupture of the tympanic membrane releases the pressure and fluid that has built up in the middle ear, leading to an immediate decrease in pain.
Choice D: An increased temperature is not a sign of a tympanic membrane rupture, as it is a nonspecific symptom that may indicate various conditions, such as inflammation, infection, or fever. An increased temperature may be associated with otitis media with effusion, which is a condition that causes fluid accumulation behind the eardrum, but it does not indicate a rupture.
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