When initiating a peripheral intravenous (IV) infusion on an infant, what action should the nurse take?

Apply soft restraints to all four extremities.

Assess the dorsal surface of the feet for an IV site.

Instruct parents to sing or croon to the infant.

Select a site that is least restrictive to the infant.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Applying soft restraints to all four extremities of an infant is not typically recommended when initiating a peripheral intravenous (IV) infusion. Restraints can cause distress and may not be necessary for the procedure.
Choice B rationale
While the dorsal surface of the feet can be used as an IV site, it is not typically the first choice for infants. The veins in the feet can be difficult to access and the location can be inconvenient for the infant.
Choice C rationale
Instructing parents to sing or croon to the infant can be comforting and may help soothe the infant during the procedure. However, this action alone does not directly facilitate the successful initiation of an IV infusion.
Choice D rationale
Selecting a site that is least restrictive to the infant is the most appropriate action when initiating a peripheral IV infusion. This can make the procedure less distressing for the infant and allow for easier movement after the IV is in place.

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Correct Answer is D

Explanation

The correct answer is choice d. Measure the blood pressure twice more during the visit and calculate the average of the three readings.

Choice A rationale:

Referring the child to the healthcare provider and scheduling a blood pressure evaluation in two weeks is not the immediate next step. It is important to confirm the elevated blood pressure reading during the same visit before making any referrals.

Choice B rationale:

Performing a comprehensive assessment and avoiding repeated blood pressure measurements is not appropriate. Repeated measurements are necessary to confirm the initial finding of elevated blood pressure.

Choice C rationale:

Taking the child’s blood pressure three times and recording the highest reading is not the best practice. The highest reading might not be representative of the child’s true blood pressure.

Choice D rationale:

Measuring the blood pressure twice more during the visit and calculating the average of the three readings is the correct approach. This method helps to ensure that the blood pressure reading is accurate and not influenced by temporary factors such as anxiety or movement.

A. Jaundice B. Swelling in the hands or feet C. Ulcers on the legs D. Chest pain

Correct Answer is D

Explanation

Choice D rationale
In a child with sickle cell disease experiencing a sickle cell crisis, chest pain is a serious symptom that should be reported to the healthcare provider immediately. Chest pain could indicate a life-threatening complication known as acute chest syndrome, which is a leading cause of death in people with sickle cell disease.
Choice A rationale
Jaundice is a common symptom in sickle cell disease due to the rapid breakdown of red blood cells, leading to an increase in bilirubin levels. While it should be monitored, it is not typically a symptom that requires immediate medical attention.
Choice B rationale
Swelling in the hands or feet, also known as dactylitis, is a common early symptom of sickle cell disease in children. It is caused by the sickle-shaped red blood cells blocking blood flow to the hands and feet.
Choice C rationale
Leg ulcers are a common complication of sickle cell disease, particularly in adults. They occur less frequently in children and are usually a sign of disease severity.

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When initiating a peripheral intravenous (IV) infusion on an infant, what action should the nurse take?

Nursing Test Bank

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