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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Excessive crying is a common symptom of neonatal abstinence syndrome. This is because the baby is experiencing withdrawal symptoms after being exposed to drugs in the womb before birth.
Choice B rationale
Normal sleep patterns are not typically associated with neonatal abstinence syndrome. Infants with this condition often have sleep problems.
Choice C rationale
Decreased muscle tone is not a common symptom of neonatal abstinence syndrome. In fact, these infants often have tight muscle tone and overactive reflexes.
Choice D rationale
Increased appetite is not a typical symptom of neonatal abstinence syndrome. These infants often have poor feeding and sucking, which could lead to poor weight gain.
Correct Answer is A
Explanation
Choice A rationale:
Developmental dysplasia of the hip (DDH) is a condition in which the hip joint is not properly formed or is unstable. Asymmetric thigh folds are a common finding in infants with DDH, as the affected hip may be dislocated or subluxated, leading to a difference in thigh fold appearance.
Choice B rationale:
An inwardly turned foot is not a specific indication of DDH. Instead, it may suggest other conditions, such as clubfoot or metatarsus adductus (no reference).
Choice C rationale:
Absent plantar reflexes are not associated with DDH. This finding might indicate a neurological issue or spinal cord injury (no reference).
Choice D rationale:
A lengthened thigh is not a typical finding in DDH. Instead, a shortened thigh on the affected side might be present due to the displacement of the femoral head (no reference).
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