A nurse is preparing to administer an oral elixir to a 3-month-old infant using an oral medication syringe. Which of the following actions should the nurse plan to take?

Measure the elixir in a medicine cup before transferring to a syringe

Place the infant supine in a crib prior to administration.

Position the syringe to the side of the infant's tongue.

Mix the medication with 10 mL of formula.

Answer and Explanation

The Correct Answer is C

A. Measure the elixir in a medicine cup before transferring to a syringe:

This option involves measuring the medication using a medicine cup before transferring it to an oral medication syringe. While measuring the medication accurately is important, transferring it from a medicine cup to a syringe introduces an extra step that may increase the risk of spillage or dosage error. It's generally more efficient and accurate to directly draw the medication into the oral syringe.

B. Place the infant supine in a crib prior to administration:

Placing the infant in a supine (lying flat on the back) position in a crib prior to administering oral medication is not recommended, particularly for infants of this age. This position increases the risk of choking or aspiration, as it may cause the medication to flow toward the back of the throat rather than being swallowed properly. It's safer to administer oral medication to infants in an upright or slightly reclined position.

C. Position the syringe to the side of the infant's tongue:

This is the correct choice. Positioning the syringe to the side of the infant's tongue helps facilitate swallowing and reduces the risk of choking or aspiration. Placing the syringe toward the cheek allows the infant to more easily swallow the medication, as it minimizes the chance of the medication flowing toward the back of the throat.

D. Mix the medication with 10 mL of formula:

Mixing medication with formula is not a standard practice for administering oral medication using an oral syringe, particularly without specific instructions from the healthcare provider. Mixing medication with formula may alter the medication's effectiveness and is unnecessary for most oral medications. It's important to administer oral medication directly using an oral syringe to ensure accurate dosing and effectiveness.

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Correct Answer is C

Explanation

A. "I will restrict the amount of salt in my child's meals."

Restricting salt intake is not typically recommended for children with cystic fibrosis (CF). In fact, individuals with CF often have increased salt requirements due to excessive salt loss through sweat. Restricting salt intake could potentially lead to electrolyte imbalances. Therefore, this statement does not demonstrate an understanding of the dietary management necessary for CF.

B. "I will put my child in daycare to ensure that she socializes with other children."

While socialization is important for a child's development, placing a child with CF in daycare may increase their risk of exposure to respiratory infections, which can be particularly dangerous for individuals with CF due to their compromised respiratory function. Therefore, this statement does not demonstrate an understanding of the infection control measures necessary for managing CF.

C. "I will make sure my child washes her hands before eating.”

This statement demonstrates an understanding of infection control measures, which are crucial for individuals with CF to reduce the risk of respiratory infections. Washing hands before eating helps prevent the transmission of bacteria and viruses that can cause respiratory infections. Therefore, this statement indicates an understanding of an important aspect of managing CF.

D. “I will provide low-fat meals for my child."

Providing low-fat meals is not typically recommended for children with CF. CF often leads to malabsorption of fats, so a diet high in calories and fat is typically recommended to ensure adequate nutrition and weight gain. Therefore, this statement does not demonstrate an understanding of the dietary recommendations necessary for managing CF.

A. Lethargy B. Urine output 70 mL in 2 hr C. Lying flat on the unaffected side D. Respiratory rate 20/min

Correct Answer is A

Explanation

A. Lethargy: Lethargy can be a concerning sign in a postoperative child, especially following a procedure involving the central nervous system like VP shunt insertion. It could indicate increased intracranial pressure or other neurological complications, which require immediate attention. Therefore, this is a priority finding.

B. Urine output 70 mL in 2 hr: While monitoring urine output is important for assessing hydration and renal function, a urine output of 70 mL in 2 hours may not be immediately concerning in a 4-year-old child. However, if this pattern continues or if there are signs of dehydration, it should be addressed. It's not as urgent as assessing for neurological changes.

C. Lying flat on the unaffected side: The positioning of the child, lying flat on the unaffected side, may or may not be concerning depending on the specific instructions provided postoperatively. While positioning can affect the function of the VP shunt, it may not necessarily indicate an immediate complication.

D. Respiratory rate 20/min: A respiratory rate of 20 breaths per minute is within the normal range for a 4-year-old child. While changes in respiratory rate can indicate respiratory distress, this respiratory rate alone is not immediately concerning.

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