A nurse is collecting data about an IV infusion site on an infant’s left hand.
Which of the following findings should the nurse identify as an indication of an infiltration?

Edema in the palm of the hand.

Absence of blanching at the insertion site.

Warmth around the insertion site.

Blood in the IV tubing.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Edema in the palm of the hand is a sign of IV infiltration. IV infiltration occurs when IV fluids or medications leak into the surrounding tissues outside the intended vein. This can cause swelling or edema, which is a common sign of infiltration.

Choice B rationale

Absence of blanching at the insertion site is not necessarily an indication of an infiltration. Blanching (whitening of the skin) can occur due to various reasons, including pressure on the site or a reaction to the IV fluid or medication. However, it is not a definitive sign of infiltration.

Choice C rationale

Warmth around the insertion site is not a definitive sign of an infiltration. While warmth can occur due to inflammation or infection, it is not a specific sign of infiltration.

Choice D rationale

Blood in the IV tubing is not a definitive sign of an infiltration. While blood can back up into the IV tubing due to various reasons, including a blocked or kinked catheter, it is not a specific sign of infiltration.

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Correct Answer is C

Explanation

Choice A rationale

This response is inappropriate and unprofessional. It makes an assumption about the child’s behavior at home without any evidence. It also could make the parents feel blamed or judged, which is not conducive to a supportive healthcare environment.

Choice B rationale

While it’s important for the nurse to communicate with the provider about any changes in the child’s health status, this response does not directly address the parents’ concern. It also does not provide reassurance or information about why the bedwetting might be occurring.

Choice C rationale

This response is empathetic and informative. It normalizes the child’s behavior by explaining that regression is common in hospitalized children. It also reassures the parents that the bedwetting is likely temporary and will improve as the child recovers.

Choice D rationale

While this response is empathetic, it does not directly address the parents’ concern about the bedwetting. It also personalizes the situation by bringing the nurse’s own children into the conversation, which is generally not recommended in professional healthcare communication.

A. Mix the medication with 10 mL of formula. B. Measure the elixir in a medicine cup before transferring to a syringe. C. Position the syringe to the side of the infant’s tongue. D. Place the infant supine in a crib prior to administration.

Correct Answer is C

Explanation

The correct answer is C. When administering an oral elixir to a 3-month-old infant using an oral medication syringe, the nurse should position the syringe to the side of the infant’s tongue. This prevents the medication from being administered too quickly and reduces the risk of choking.

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A nurse is collecting data about an IV infusion site on an infant’s left hand.Which of the following findings should the nurse identify as an indication of an infiltration?

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A nurse is collecting data about an IV infusion site on an infant’s left hand.
Which of the following findings should the nurse identify as an indication of an infiltration?