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 A
Explanation
Choice A reason: Applying nitroglycerin ointment in a thin, even layer ensures consistent absorption for angina relief, as specified by dosing guidelines (e.g., using a dosing paper). This maximizes efficacy and minimizes side effects like hypotension, aligning with manufacturer instructions, making it the correct teaching point.
Choice B reason: Applying to the forearm is not standard, as nitroglycerin ointment is typically applied to the chest, upper arm, or back for optimal absorption. Forearm application may reduce effectiveness due to skin thickness, making this an incorrect site choice.
Choice C reason: Applying every 4 hours is incorrect, as nitroglycerin ointment is typically applied 2-3 times daily, with a 12-hour nitrate-free interval to prevent tolerance. This frequency is too frequent and risks side effects, making it an inaccurate instruction.
Choice D reason: Massaging nitroglycerin ointment into the skin is contraindicated, as it alters absorption rates and may cause inconsistent dosing or irritation. The ointment is spread lightly and covered, making this instruction incorrect and potentially harmful for proper administration.
Correct Answer is D
Explanation
Choice A reason: Contractions lasting 60 seconds every 5 minutes are normal for active labor, indicating effective uterine activity to progress delivery. This does not require immediate reporting, as it aligns with expected labor patterns and does not indicate fetal or maternal distress, making it a non-urgent finding.
Choice B reason: A fetal heart rate of 140 beats per minute is within the normal range (110-160 bpm) for a fetus in labor. This indicates fetal well-being and does not require reporting unless accompanied by abnormal patterns like decelerations, making this finding normal and not urgent.
Choice C reason: A maternal blood pressure of 120/80 mmHg is normal and does not indicate distress or complications like preeclampsia. It does not require reporting, as it reflects stable maternal hemodynamics during labor, making this finding non-urgent compared to fetal heart rate abnormalities.
Choice D reason: Late decelerations in the FHR indicate uteroplacental insufficiency, reducing fetal oxygenation and risking hypoxia. This requires immediate reporting to the provider for interventions like position changes or oxygen administration to prevent fetal distress, making it the critical finding necessitating urgent action.
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