A nurse is preparing to insert a peripheral intravenous line on an infant. Which of the following actions should the nurse plan to take?
Use gauze to cover the IV insertion site.
Monitor the IV site every 8 hours.
Insert the catheter into the foot.
Obtain a 24-gauge catheter.
The Correct Answer is D
Choice A reason: Using gauze to cover an infant’s IV site obscures visualization, delaying detection of infiltration or infection. Transparent dressings are preferred, as infants’ small veins are prone to complications. Gauze increases risk by hiding signs like swelling, critical for early intervention in pediatric IV management.
Choice B reason: Monitoring an IV site every 8 hours is inadequate for infants, who need hourly checks due to small vein fragility and high infiltration risk. Frequent assessment detects complications like phlebitis or extravasation early, ensuring vascular integrity and preventing tissue damage in pediatric patients.
Choice C reason: Inserting an IV in the foot is less preferred, as scalp or hand veins are more accessible and stable in infants. Foot IVs risk dislodgement from movement and may impair circulation, increasing complications like tissue damage, making this a suboptimal choice for IV placement.
Choice D reason: A 24-gauge catheter is ideal for infants, as their small veins require smaller needles to minimize trauma and infiltration. This size ensures adequate fluid or medication delivery while reducing vascular damage, aligning with pediatric IV guidelines for safe and effective venous access.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Amitriptyline, a tricyclic antidepressant, typically causes hypotension via alpha-adrenergic blockade, not hypertension. Expecting blood pressure elevation shows misunderstanding, as its cardiovascular effects require monitoring for orthostatic changes, not hypertensive risks, in depression treatment.
Choice B reason: Acknowledging a 2-4 week delay for amitriptyline’s effect shows understanding, as tricyclics increase synaptic serotonin and norepinephrine gradually, requiring neuroplastic changes for mood improvement. This reflects accurate knowledge of the drug’s onset, critical for managing expectations in depression therapy.
Choice C reason: Taking amitriptyline on an empty stomach is incorrect, as food reduces gastrointestinal side effects like nausea. Its absorption is unaffected by food, but taking it with meals improves tolerability, indicating a misunderstanding of administration guidelines for effective therapy.
Choice D reason: Morning dosing of amitriptyline is incorrect, as its sedative effects, via histamine blockade, are best utilized at bedtime to aid sleep. Morning use may cause daytime drowsiness, reducing adherence, indicating a misunderstanding of its pharmacological profile in depression management.
Correct Answer is D
Explanation
Choice A reason: Maternal fever may cause fetal tachycardia, not bradycardia, as it increases metabolic demand. While fever can indicate infection, it does not directly lower FHR to 100/min, making it an incorrect cause for sustained fetal bradycardia in this scenario.
Choice B reason: Chorioamnionitis, an intrauterine infection, typically causes fetal tachycardia due to stress and inflammation, not bradycardia. While serious, it does not align with a sustained FHR of 100/min, making it incorrect for this fetal condition.
Choice C reason: Maternal hypoglycemia may cause fetal distress, but it is more likely to result in tachycardia or variable decelerations, not sustained bradycardia. Its impact on FHR is less direct, making it an incorrect primary cause for this finding.
Choice D reason: Fetal anemia reduces oxygen-carrying capacity, leading to sustained bradycardia (FHR <110/min) due to hypoxia. This condition, often from hemolytic disease or bleeding, directly causes low FHR, requiring urgent evaluation, making it the correct cause.
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