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: This instruction is incorrect, as withholding insulin dose if feeling nauseous can cause hyperglycemia, which is high blood sugar, and diabetic ketoacidosis, which is a life-threatening condition that occurs when the body breaks down fat for energy and produces ketones. Ketones are acidic substances that can cause nausea, vomiting, abdominal pain, dehydration, or coma. The child should take their insulin dose as prescribed and monitor their blood sugar levels more frequently when they are sick.

Choice B: This instruction is unnecessary, as notifying the provider if blood glucose levels are within normal parameters does not require any action or intervention. The child and the parents should notify the provider if blood glucose levels are above or below the target range, which is usually 70 to 180 mg/dL for children with type 1 diabetes mellitus. The child and the parents should also notify the provider if they have any signs or symptoms of hypoglycemia, hyperglycemia, or diabetic ketoacidosis.

Choice C: This instruction is incorrect, as limiting ﬂuid intake during mealtime can cause dehydration, which can worsen the symptoms and complications of type 1 diabetes mellitus. Dehydration can cause increased thirst, dry mouth, fatigue, headache, or dizziness. The child should drink plenty of ﬂuids during meal time and throughout the day to hydrate their body and ﬂush out excess glucose and ketones.

Choice D: This instruction is correct, as testing the urine for ketones can help detect diabetic ketoacidosis, which is a life-threatening condition that occurs when the body breaks down fat for energy and produces ketones. Ketones are acidic substances that can cause nausea, vomiting, abdominal pain, dehydration, or coma. The child should test their urine for ketones when their blood sugar levels are above 240 mg/dL or when they are sick. The child and the parents should notify the provider if the urine test shows moderate or large amounts of ketones.

A. "Your baby will receive first diphtheria, tetanus, and pertussis vaccine at the 2-week well-baby visit." B. "Your baby will receive a hepatitis B vaccine prior to discharge." C. "Your baby should receive the measles, mumps, rubella vaccine at 6 months." D. "Your baby should receive the pneumococcal conjugate vaccine on his first birthday."

Correct Answer is B

Explanation

Choice A: This information is incorrect, as the first dose of the diphtheria, tetanus, pertussis (DTaP) vaccine is usually given at 2 months of age, not 2 weeks. The DTaP vaccine protects against three serious bacterial diseases that can cause respiratory infections, nerve damage, or death. The DTaP vaccine is given in five doses at 2, 4, 6, 15 to 18 months, and 4 to 6 years of age.

Choice B: This information is correct, as the first dose of the hepatitis B vaccine is usually given within 24 hours of birth or prior to discharge from the hospital. The hepatitis B vaccine protects against a viral infection that can cause liver inﬂammation, cirrhosis, or cancer. The hepatitis B vaccine is given in three doses at birth, 1 to 2 months, and 6 to 18 months of age.

Choice C: This information is incorrect, as the first dose of the measles, mumps, rubella (MMR) vaccine is usually given at 12 to 15 months of age, not 6 months. The MMR vaccine protects against three viral diseases that can cause fever, rash, swelling of glands, or complications such as pneumonia, encephalitis, or deafness. The MMR vaccine is given in two doses at 12 to 15 months and 4 to 6 years of age.

Choice D: This information is incorrect, as the first dose of the pneumococcal conjugate (PCV13) vaccine is usually given at 2 months of age, not on the first birthday. The PCV13 vaccine protects against a bacterial infection that can cause pneumonia, meningitis, or sepsis. The PCV13 vaccine is given in four doses at 2, 4, 6, and 12 to 15 months of age.

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