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.
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Related Questions
Correct Answer is C
Explanation
Choice A: Improving the client's school attendance skills is not the priority goal for a child who has hemiplegic cerebral palsy, which is a condition that affects one side of the body and causes muscle weakness, spasticity, and impaired coordination. Improving the client's school attendance skills is a long-term goal that requires collaboration with the school staff, the child, and the parents. The priority goal for a child who has hemiplegic cerebral palsy is to ensure their safety and mobility at home.
Choice B: Providing teaching on self-care activities is not the priority goal for a child who has hemiplegic cerebral palsy, which is a condition that affects one side of the body and causes muscle weakness, spasticity, and impaired coordination. Providing teaching on self-care activities is an important goal that requires assessment of the child's abilities, needs, and preferences. The priority goal for a child who has hemiplegic cerebral palsy is to ensure their safety and mobility at home.
Choice C: Modifying the environment for optimal safety and mobility is the priority goal for a child who has hemiplegic cerebral palsy, which is a condition that affects one side of the body and causes muscle weakness, spasticity, and impaired coordination. Modifying the environment for optimal safety and mobility can prevent falls, injuries, or complications and promote independence and function. The nurse should include interventions such as removing clutter, securing rugs, installing grab bars, providing adaptive equipment, and arranging furniture.
Choice D: Providing counseling services for the parents is not the priority goal for a child who has hemiplegic cerebral palsy, which is a condition that affects one side of the body and causes muscle weakness, spasticity, and impaired coordination. Providing counseling services for the parents is a supportive goal that requires referral to appropriate resources, such as social workers, psychologists, or support groups. The priority goal for a child who has hemiplegic cerebral palsy is to ensure their safety and mobility at home.
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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