When starting a peripheral intravenous (IV) infusion on an infant, which intervention should the nurse implement?
Select a site that is least restrictive to the infant.
Assess dorsal surface of feet for an IV site.
Instruct parents to sing or croon to the infant.
Apply soft restraints to all four extremities.
The Correct Answer is A
Peripheral intravenous (IV) infusion is a common procedure performed on infants in a hospital setting. The selection of the IV site is critical to ensure proper placement and to prevent complications.
When starting a peripheral IV infusion on an infant, the nurse should select a site that is least restrictive to the infant. This involves selecting a site that will not restrict the infant's movement and cause discomfort. The site should be accessible, visible, and easily palpable, such as the hand, wrist, or antecubital fossa.
Assessing the dorsal surface of the feet for an IV site is not recommended as it is an area of high risk for infiltration and may restrict the infant's movement.
Instructing parents to sing or croon to the infant may provide comfort and distraction, but it is not a critical intervention when starting a peripheral IV infusion.
Applying soft restraints to all four extremities is not recommended as it may cause physical and emotional distress to the infant. It should only be used as a last resort if the infant is at high risk of self-injury or if the procedure cannot be safely performed without restraints.
Therefore, the nurse should implement the intervention of selecting a site that is least restrictive to the infant when starting a peripheral IV infusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Rationale:
(A) Repair should be done before the child is potty-trained: Surgical correction of hypospadias is typically recommended before the child reaches the age of 18 months, ideally between 6 and 12 months. This timing ensures that the child has not yet developed any psychological awareness of the surgery and helps avoid complications during toilet training. Repair before potty training is important to prevent urinary dysfunction and psychosocial issues.
(B) The urethral repair should be done after sexual maturity: Delaying surgical repair until after sexual maturity is not recommended. Early repair is crucial to ensure normal urinary and sexual function, and delaying it could lead to complications such as difficulty with urination and psychological distress.
(C) Surgery should be done by one month to prevent bladder infections: While preventing urinary tract infections is important, performing surgery as early as one month is not typically necessary or recommended. The optimal timing is closer to 6 to 12 months of age when the child is more resilient to surgery but still before the developmental milestones of potty training.
(D) Delaying the repair until school age reduces castration fears: Delaying the surgery until school age can actually increase psychological stress and fear of castration. Early surgical correction is preferred to minimize psychological impact and to allow the child to develop normally without the need for complex explanations or fear of surgery later in life.
Correct Answer is A
Explanation
The boy's reported symptoms may indicate stress or anxiety related to his school experience. By asking the boy to describe a typical day at school, the nurse can gather information about the child's interactions with teachers and peers, academic performance, and any other potential sources of stress. This information can be used to develop an appropriate plan of care that addresses the child's emotional and physical needs.
Comparing vital signs or conducting a neurological assessment may not provide useful information in this case, and counseling the parents to pay more attention to the child is not a recommended intervention without first identifying the underlying cause of the child's symptoms.
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