A nurse is assisting with preparing a toddler for an intravenous procedure.
Which of the following actions should the nurse take? (Select all that apply)

Ask the guardians to leave during the procedure.

Assist with performing the procedure with the child in his bed.

Reinforce the procedure using the child’s favorite toy.

Apply lidocaine and prilocaine (EMLA) Cream to 2-3 potential insertion sites.

Allow the child to make one choice regarding the procedure.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A rationale

Asking the guardians to leave during the procedure is not recommended. The presence of a familiar person can provide comfort and reduce anxiety for the toddler during a stressful procedure.

Choice B rationale

Performing the procedure with the child in his bed can provide a sense of security and familiarity, which can help reduce anxiety and fear.

Choice C rationale

Using the child’s favorite toy to explain or distract during the procedure can help the child understand what to expect and provide a sense of control.

Choice D rationale

Applying lidocaine and prilocaine (EMLA) Cream to 2-3 potential insertion sites can help numb the area and reduce pain during the procedure.

Choice E rationale

Allowing the child to make one choice regarding the procedure can provide a sense of control and cooperation.

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Correct Answer is A

Explanation

Choice A rationale

Lethargy in a child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt could indicate a serious problem such as shunt malfunction or infection, and should be the priority.

Choice B rationale

A respiratory rate of 20/min is within the normal range for a 4-year-old child and is not typically a cause for concern.

Choice C rationale

Lying flat on the unaffected side is not typically a cause for concern following ventriculoperitoneal shunt surgery.

Choice D rationale

A urine output of 50 mL in 2 hr is within the normal range for a 4-year-old child and is not typically a cause for concern.

A. The infant eats the same foods prepared for the rest of the family. B. The infant drinks 2 quarts of whole milk a day. C. The infant drinks from a cup with a cover. D. The mother gives the infant finger foods, such as apple slices for a snack.

Correct Answer is B

Explanation

Choice A rationale

It’s not uncommon for infants to eat the same foods prepared for the rest of the family, especially if these foods are healthy and properly prepared. However, it’s important to note that certain foods may pose a choking hazard or may not be suitable for an infant’s digestive system. For example, honey should not be given to children under 1 year of age due to the risk of botulism.

Choice B rationale

The American Academy of Pediatrics recommends that infants under 12 months of age should not drink cow’s milk. Cow’s milk lacks the necessary nutrients that infants need for growth and development. It also contains high concentrations of protein and minerals, which can stress an infant’s kidneys and cause other health problems.

Choice C rationale

Drinking from a cup with a cover, also known as a sippy cup, is a normal part of an infant’s development. It helps the child transition from a bottle to a regular cup. However, it’s important to monitor the child’s use of a sippy cup as prolonged use can lead to tooth decay.

Choice D rationale

Giving an infant finger foods like apple slices is a good way to encourage self-feeding and develop fine motor skills. However, the food should be cut into small, manageable pieces to prevent choking.

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A nurse is assisting with preparing a toddler for an intravenous procedure. Which of the following actions should the nurse take? (Select all that apply)

Nursing Test Bank

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A nurse is assisting with preparing a toddler for an intravenous procedure.
Which of the following actions should the nurse take? (Select all that apply)