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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: Ibuprofen is a nonsteroidal anti-inﬂammatory drug (NSAID) that can be used to relieve pain and inﬂammation in children with inﬂuenza. Ibuprofen does not increase the risk of Reye syndrome, which is a rare but serious condition that affects the brain and liver.

Choice B: Grapefruit juice is a citrus fruit that can provide vitamin C and hydration for children with inﬂuenza. Grapefruit juice does not increase the risk of Reye syndrome, but it can interact with some medications and affect their absorption or metabolism.

Choice C: A humidifier is a device that adds moisture to the air and can help ease congestion and coughing in children with inﬂuenza. A humidifier does not increase the risk of Reye syndrome, but it should be cleaned regularly to prevent bacterial growth and infection.

Choice D: Aspirin is a salicylate that can be used to reduce fever and inﬂammation in children with inﬂuenza. However, aspirin can increase the risk of Reye syndrome, especially in children who have viral infections. Reye syndrome can cause swelling in the brain, liver damage, and even death. Therefore, aspirin should be avoided in children under 19 years old who have inﬂuenza or other viral illnesses.

A. Popping sensation when swallowing B. Green-blue discharge in the ear canal C. Sudden pain relief D. Increased temperature

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has inﬂuenza. The nurse should identify which of the following statements by the parent indicates the child has an increased risk for Reye syndrome.

Correct Answer is D

Explanation

A nurse is caring for a child who has otitis media with eﬀusion. The nurse should identify which of the following manifestations indicates a tympanic membrane rupture.

Correct Answer is C

Explanation

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