A nurse is planning care for an 8-month-old infant with a tracheostomy. Which of the following actions should the nurse include in the plan of care?
Use a bulb syringe to suction the nares.
Provide antibiotic therapy.
Administer intermittent suction via the tracheostomy.
Place the infant in a prone position to sleep.
The Correct Answer is C
Choice A reason: Using a bulb syringe to suction the nares is a common practice for clearing nasal passages in infants, but it is not the primary concern for an infant with a tracheostomy, which requires specific care to maintain airway patency.
Choice B reason: Providing antibiotic therapy may be necessary if there is an infection, but it is not a standard care action for a tracheostomy without evidence of infection.
Choice C reason: Administering intermittent suction via the tracheostomy is essential to clear secretions and maintain airway patency, which is the greatest risk for an infant with a tracheostomy.
Choice D reason: Placing an infant in a prone position to sleep is not recommended due to the increased risk of sudden infant death syndrome (SIDS). Infants should be placed on their backs to sleep.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Asking the parent to leave the room during the injections is not recommended as the presence of a parent can provide comfort to the infant, which may help in reducing pain and anxiety.
Choice B reason: Administering the injections while the infant is breastfeeding is an effective method to decrease pain. Breastfeeding provides comfort and distraction, and the natural sugars in breast milk can have a mild analgesic effect.
Choice C reason: Applying a warm pack to the injection site prior to administration is not a standard practice for reducing pain from immunizations. Instead, using a cold compress after the injection can help to reduce swelling and discomfort.
Choice D reason: Administering injections in the deltoid muscle is not appropriate for a 2-month-old infant due to the underdeveloped muscle mass. The anterolateral thigh is the recommended site for immunizations in infants.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Loosening tight clothing around the child's neck is important to ensure that the child can breathe easily and to prevent any additional discomfort or injury during the seizure.
Choice B reason: It is not recommended to firmly hold the child's arms to one side as this can cause injury. Instead, the nurse should ensure the child's safety by clearing the area of any hard or sharp objects.
Choice C reason: Placing a pillow under the child's head can help to protect the head from injury during the seizure. It provides a soft cushion to prevent the child from hitting their head on hard surfaces.
Choice D reason: Inserting a tongue blade into the child's mouth is not advised as it can cause injury to the child's mouth or teeth, and there is a risk of the child biting down and breaking the blade.
Choice E reason: Clearing the area of hard objects is crucial to prevent injury to the child during the seizure. Removing any potential hazards ensures a safer environment for the child to move without harm.
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