A nurse is planning care for an infant who has a prescription for a Pavlik harness. Which of the following actions should the nurse take?
Apply lotion to the skin beneath the straps twice daily.
Position the diaper over the straps with each change.
Lengthen the harness straps weekly.
Massage the skin under the straps daily.
The Correct Answer is B
A. Lotions, powders, or ointments should be avoided under the harness as they can irritate the skin.
B. This helps protect the skin and keeps the harness clean.
C. Only a healthcare provider should adjust the harness straps. Parents should not attempt to do this.
D. Massage can irritate the skin and should be avoided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A hemoglobin level of 6.8 g/dL is lower than the normal range for a child (9.5 to 14 g/dL). This indicates anemia, which is a common issue in leukemia due to the disease affecting red blood cell production. Although this level is concerning, it does not necessarily reflect a therapeutic effect of treatment.
B. A WBC count of 15,000/mm³ is elevated compared to the normal range (5,000 to 10,000/mm³). In the context of ALL, high white blood cell counts can indicate active disease or ineffective treatment. Therapeutic effects are generally indicated by a reduction in WBC count towards the normal range.
C. The RBC count of 5/mm³ is within the normal range for a 4-year-old child (4 to 5.5/mm³). This finding suggests that red blood cell production is relatively stable. However, in the context of leukemia treatment, the focus is often on other indicators such as WBC count and platelet count to assess treatment effectiveness
D. A platelet count of 98,000/mm³ is lower than the normal range (150,000 to 400,000/mm³), indicating thrombocytopenia (low platelet count). In children with leukemia, treatment often aims to normalize platelet counts or at least improve them from very low levels.
Correct Answer is D
Explanation
A. Crying is a common response to post-operative pain. While it should be addressed, it's not the most critical concern.
B. Adequate hydration is essential, but it's not as critical as the risk of hemorrhage.
C. Pain management is crucial, but it's not the most immediate concern.
D. Frequent swallowing is a classic sign of postoperative hemorrhage. It indicates the child is trying to clear blood from the throat. This is the priority assessment finding and requires immediate intervention.
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