The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?
Instruct the mother to change the child's diaper more often.
Ask the mother to decrease the infant's intake of fruits for 24 hours.
Encourage the mother to apply lotion with each diaper change.
Tell the mother to cleanse with soap and water at each diaper change.
The Correct Answer is A
The excoriated and red skin in the diaper area suggests the presence of diaper dermatitis, which is commonly caused by prolonged exposure to moisture and irritants such as urine and feces. Changing the diaper more frequently helps to minimize the exposure to these irritants and promotes better skin hygiene.
Asking the mother to decrease the infant's intake of fruits for 24 hours is not necessary unless there is evidence of diarrhea or specific dietary concerns. Fruits are generally a healthy part of an infant's diet and do not directly cause diaper dermatitis.
Encouraging the mother to apply lotion with each diaper change may not be recommended in this case, as lotions and creams can further trap moisture and exacerbate the condition. It is best to keep the area clean and dry.
Telling the mother to cleanse with soap and water at each diaper change may be too harsh for the infant's sensitive skin. Plain water or mild, fragrance-free wipes are typically sufficient for cleaning the diaper area. Soap can be drying and irritating to the skin, so it is generally not necessary unless there is a specific indication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
It is important to assess the child's vital signs, including oxygen saturation (SaO2), to ensure their stability and identify any signs of respiratory distress or other abnormalities that may impact medication administration.
Prior to administering any medication, it is crucial to verify if the child has any known allergies to medications. This information is essential for ensuring the safety of the child and preventing any potential allergic reactions.
Before administering pain medication, the nurse must verify that the prescribed dosage is appropriate for the child's age, weight, and condition. Ensuring the correct dosage helps prevent medication errors and potential adverse effects.
It is important to use a validated pain assessment tool that is appropriate for the child's age and cognitive abilities. This allows for a comprehensive and accurate assessment of the child's pain level, helping guide appropriate pain management interventions.
Considering the child has cognitive and speech delays, the input from the parent regarding the child's pain is valuable. The nurse should assess and consider the parent's report of the child's pain in conjunction with other assessment findings to ensure effective pain management.
Subjective pain assessment is mentioned as a finding but may not require immediate action, as it needs to be combined with other assessment data for a comprehensive evaluation.
Correct Answer is ["B","C","D"]
Explanation
A) Incorrect- Standard precautions are used for all clients to prevent the spread of infections.
However, in the case of MRSA, contact precautions are needed due to the risk of direct transmission through physical contact.
B) Correct- Monitoring the white blood cell count is important to assess for signs of infection, as an elevated count might indicate an ongoing inflammatory response.
C) Correct- Foul-smelling drainage from an incision with suspected MRSA indicates a potential infection. Contact precautions are appropriate for MRSA, which include wearing gloves and gowns when entering the client's room to prevent the spread of the bacteria.
D) Correct- Sending wound drainage for culture and sensitivity helps identify the specific microorganisms causing the infection and guides appropriate antibiotic treatment.
E) Incorrect- A low-bacteria diet is not relevant to the situation. MRSA is caused by a bacterium, not by dietary factors. The focus should be on infection control measures and appropriate medical interventions.
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