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 ["B","C"]
Explanation
Choice A: Clubbing of the nail beds is not a finding that the nurse should expect in a child who has aortic stenosis, which is a condition that causes narrowing of the aortic valve and obstructs blood flow from the left ventricle to the aorta. Clubbing of the nail beds is a sign of chronic hypoxia, which can occur in conditions that affect the lungs or the right side of the heart.
Choice B: Murmur is a finding that the nurse should expect in a child who has aortic stenosis, as it indicates turbulent blood flow through the narrowed valve. A murmur can be heard with a stethoscope over the chest and may vary in intensity, pitch, and duration. A murmur caused by aortic stenosis is typically systolic, loud, and harsh and radiates to the neck or back.
Choice C: Weak pulses are a finding that the nurse should expect in a child who has aortic stenosis, as they indicate reduced blood flow and pressure in the peripheral arteries. Weak pulses can be felt with palpation of the radial, brachial, femoral, or pedal arteries and may be difficult to detect or absent.
Choice D: Bradycardia is not a finding that the nurse should expect in a child who has aortic stenosis, as it indicates a slow heart rate, which is less than 60 beats per minute in children. Bradycardia can occur in conditions that affect the electrical conduction system of the heart or cause increased vagal tone. A child who has aortic stenosis may have tachycardia, which is a fast heart rate, as a compensatory mechanism to increase cardiac output.
Choice E:Hypertension is not typically associated with aortic stenosis in children; instead, the condition often results in reduced blood pressure distal to the valve.
Correct Answer is ["A","C","E"]
Explanation
Choice A: Allowing the child to keep a toy from home with her can help reduce her fear and anxiety by providing comfort, distraction, and familiarity. This strategy can also enhance the child's sense of control and autonomy by letting her choose what toy to bring.
Choice B: Using mummy restraints during painful procedures can increase the child's fear and anxiety by making her feel trapped, helpless, and powerless. This strategy can also damage the child's trust and cooperation with the nurse and cause psychological trauma.
Choice C: Having a parent stay with the child during procedures can help reduce her fear and anxiety by providing support, reassurance, and security. This strategy can also enhance the child's coping skills and resilience by modeling calm and positive behaviors.
Choice D: Planning invasive procedures whenever possible can increase the child's fear and anxiety by exposing her to unnecessary pain and discomfort. This strategy can also impair the child's physical and emotional development by causing stress and inflammation.
Choice E: Performing the procedure as quickly as possible can help reduce her fear and anxiety by minimizing the duration and intensity of pain. This strategy can also enhance the child's satisfaction and compliance by showing respect and empathy.
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