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 A
Explanation
Choice A: This response is appropriate, as it indicates urgency and concern for the infant's condition. Projectile vomiting immediately after eating can be a sign of pyloric stenosis, which is a condition that causes the narrowing of the pylorus, which is the opening between the stomach and the small intestine. Pyloric stenosis can prevent food from passing through and cause dehydration, electrolyte imbalance, or weight loss. The infant needs to be evaluated by a provider as soon as possible and may need surgery to correct the problem.
Choice B: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Oral rehydration solution can help replace fluids and electrolytes lost through vomiting, but it does not treat pyloric stenosis or prevent further vomiting. Oral rehydration solution may also be vomited out by the infant if given too soon or too much.
Choice C: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Burping the baby more frequently during feedings can help release air bubbles and prevent gas or colic, but it does not treat pyloric stenosis or prevent further vomiting. Burping may also trigger vomiting by increasing pressure on the stomach.
Choice D: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Switching to a different formula can help if the infant has an allergy or intolerance to certain ingredients in their current formula, but it does not treat pyloric stenosis or prevent further vomiting. Switching formulas may also cause diarrhea or constipation by changing the infant's bowel flora.
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect because constructing a model airplane is not an appropriate activity for a 4- year-old child who requires airborne precautions. Airborne precautions are infection control measures that prevent the transmission of microorganisms that can be spread by small droplets that remain suspended in the air, such as tuberculosis, measles, or chickenpox. They involve placing the child in a negative-pressure room with a HEPA filter, wearing a respirator mask, and limiting movement outside the room. Constructing a model airplane may involve small parts that can be choking hazards, sharp edges that can cause injury or glue that can cause irritation or allergy. Therefore, this activity may not be safe or suitable for the child.
Choice B reason: This choice is incorrect because pulling a wagon with toys in the hallway is not an appropriate activity for a 4-year-old child who requires airborne precautions. As explained above, airborne precautions involve limiting movement outside the room to prevent exposure and transmission of microorganisms. Pulling a wagon with toys in the hallway may violate these precautions and increase the risk of infection for the child and others.
Therefore, this activity may not be allowed or advisable for the child.
Choice C reason: This choice is correct because putting a large-piece puzzle together is an appropriate activity for a 4-year-old child who requires airborne precautions. Putting a large-piece puzzle together can help to stimulate the child's cognitive, visual, and fine motor skills by requiring them to match shapes, colors, and patterns. It can also help to reduce boredom, frustration, or anxiety by providing entertainment, diversion, or achievement. Therefore, this activity may be beneficial and enjoyable for the child.
Choice D reason: This choice is incorrect because watching a video game in the playroom is not an appropriate activity for a 4-year-old child who requires airborne precautions. As explained above, airborne precautions involve limiting movement outside the room to prevent exposure and transmission of microorganisms. Watching a video game in the playroom may violate these precautions and increase the risk of infection for the child and others.
Therefore, this activity may not be permitted or recommended for the child.
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