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.

Answer and Explanation

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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Correct Answer is C

Explanation

The nurse should recognize that the statement "high-calorie formula encourages increased growth" is an appropriate understanding of interventions for an infant with FTT. High-calorie formula can help infants who are not gaining weight adequately to increase their calorie intake and promote growth.

Breast milk provides adequate nutrition for most infants, but in cases of FTT, the infant may require a higher calorie intake than breast milk can provide. Regular syringe feedings and fruit juice are not recommended interventions for FTT. Syringe feedings can cause aspiration and fruit juice does not provide the appropriate balance of nutrients needed for an infant's growth and development.

A. Refer the child to the healthcare provider and schedule evaluation of blood pressure in two weeks. B. Measure the child's blood pressure three times during the visit and determine the highest of the readings. C. Conduct a head-to-toe assessment and omit repeated blood pressures during the examination. D. Take the blood pressure two more times during the visit and determine the average of the three readings.

Correct Answer is D

Explanation

If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks

A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings

B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination

C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.

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When starting a peripheral intravenous (IV) infusion on an infant, which intervention should the nurse implement?

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