A nurse is preparing to administer carbamazepine suspension 150 mg via NG tube every 6 hr. The amount available is 100 mg/5 mL. How many mL should the nurse administer with each dose?

(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

The correct answer is: a. Remove bibs when the infant is going to sleep.

Choice A reason: Removing bibs when an infant is going to sleep is a critical safety measure to prevent suffocation and strangulation risks. Infants should have a sleep environment free of any loose objects that could cover their face and interfere with breathing. The American Academy of Pediatrics recommends keeping the crib clear of items like bibs, pillows, blankets, and toys to reduce the risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related infant deaths.

Choice B reason: Using a highchair for feedings is not recommended for a 3-month-old infant because they typically cannot sit up unsupported at this age. Highchairs are generally used when an infant can sit up well without support and has good head control, usually around 6 months old. Until then, infants should be held or placed in an appropriate reclined feeding position.

Choice C reason: A soft crib mattress is not advisable for infants. A firm mattress is essential to provide a safe sleep surface. Soft mattresses and other soft surfaces increase the risk of SIDS and suffocation because they can create pockets that may cause an infant’s face to sink in and restrict breathing.

Choice D reason: Placing pillows in the crib, even one small pillow, is unsafe for infants. Pillows can pose a suffocation hazard and increase the risk of SIDS. The crib should be kept bare, with only a firm mattress and a fitted sheet, to ensure a safe sleep environment for the infant.

Choice A rationale:

Administering an enema can help relieve the client’s abdominal cramping and small, hard, painful bowel movement. An enema is a procedure that involves introducing a liquid solution into the rectum to promote evacuation of feces. It can be used to relieve constipation, which seems to be the client’s issue based on the description of their bowel movement.

Choice B rationale:

Assisting the client with a sitz bath may not be necessary at this time. A sitz bath is typically used to soothe and cleanse the perineal area, particularly after childbirth or surgery. While the client does have a surgical incision, the notes indicate that the perineal dressing is intact with minimal serosanguinous drainage, suggesting that the incision site is not currently problematic.

Choice C rationale:

Irrigating an indwelling catheter with 500 mL of fluid is not recommended unless there is a specific indication, such as the catheter being blocked. The client’s urinary catheter is intact with 100 mL/hr of pink urine, which suggests that it is functioning properly.

Choice D rationale:

Encouraging prolonged dangling before ambulation may not be beneficial for this client. Dangling involves sitting on the edge of the bed with legs hanging down before standing up. This can help prevent dizziness upon standing. However, the notes indicate that the client is already ambulating independently in the hallway, suggesting that they do not have issues with mobility or dizziness.

Choice E rationale:

Encouraging oral fluid intake can help alleviate constipation by softening stools and promoting bowel movements. It can also help maintain hydration, which is particularly important for postoperative clients. Therefore, this would be a beneficial action for the nurse to take for this client.