A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care?
Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure.
Keep the infant NPO for 6 hr prior to the procedure.
Hold the infant's chin to his chest and knees to his abdomen during the procedure.
Place the infant in an infant seat for 2 hr following the procedure.
The Correct Answer is C
The correct answer is: c. Hold the infant’s chin to his chest and knees to his abdomen during the procedure.
Choice A: Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure.
Applying a eutectic mixture of lidocaine and prilocaine (EMLA) cream can help reduce pain during procedures like lumbar punctures. However, it typically needs to be applied 30 to 60 minutes before the procedure to be effective. Applying it only 15 minutes prior would not provide adequate analgesia.
Choice B: Keep the infant NPO for 6 hr prior to the procedure.
Keeping an infant NPO (nothing by mouth) for 6 hours is generally recommended before procedures requiring sedation or anesthesia to reduce the risk of aspiration. However, lumbar punctures do not typically require such prolonged fasting, especially in infants, unless sedation is planned.
Choice C: Hold the infant’s chin to his chest and knees to his abdomen during the procedure.
This is the correct positioning for a lumbar puncture in infants. The infant should be held in a curled-up position, with the chin to the chest and knees to the abdomen, to maximize the space between the vertebrae and allow easier access to the lumbar region. This position helps to stabilize the infant and reduce movement during the procedure.
Choice D: Place the infant in an infant seat for 2 hr following the procedure.
Post-procedure care for a lumbar puncture typically involves monitoring the infant for any signs of complications, such as headache or infection. Placing the infant in an infant seat for 2 hours is not a standard recommendation. Instead, the infant should be observed and allowed to rest comfortably.
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Related Questions
Correct Answer is D
Explanation
Choice A: Using a pain-rating tool to determine the severity of the joint pain is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. Joint pain is one of the major criteria for diagnosing acute rheumatic fever and can affect one or more large joints, such as knees, ankles, elbows, or wrists. Joint pain can be managed with analgesics or anti-inflammatory drugs.
Choice B: Assessing the client's erythematous rash is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. The erythematous rash is one of the minor criteria for diagnosing acute rheumatic fever and can appear as pink or red patches on the trunk or limbs. The erythematous rash can fade or change location over time and does not require any specific treatment.
Choice C: Identifying the degree of parental anxiety related to the diagnosis is not the priority assessment for an 8-year-old child who has acute rheumatic fever, which is an inflammatory condition that can affect various organs, especially the heart, joints, skin, and brain. Parental anxiety related to the diagnosis can affect their coping skills and ability to care for their child. Parental anxiety can be addressed by providing education, support, and referral to appropriate resources.
Choice D: Auscultating the rate and regularity of the child's heart sounds and notifying the provider immediately of abnormalities is the priority assessment for an 8-year-old child who has acute rheumatic fever, as it can indicate cardiac involvement, which is the most serious complication of acute rheumatic fever. Cardiac involvement can cause damage to the heart valves, myocardium, or pericardium and lead to heart failure or death. Abnormalities in heart sounds may include murmurs, rubs, gallops, or arrhythmias.
Correct Answer is B
Explanation
Choice A: Skin cancer is a malignant growth of the skin cells, which can be caused by exposure to ultraviolet radiation, genetic mutations, or immunosuppression. Skin cancer does not affect the mouth and does not cause a white, milky plaque. Skin cancer may cause changes in the color, shape, size, or texture of a mole or a skin lesion.
Choice B: Candidiasis or thrush is a fungal infection of the mouth, which can be caused by overgrowth of Candida albicans, a type of yeast that normally lives in the body. Candidiasis or thrush can occur in people who have a weakened immune system, such as those who have a systemic disorder, take antibiotics, immunosuppressants, or corticosteroids, or have a smoking history. Candidiasis or thrush can cause soreness in the mouth and difficulty eating. Candidiasis or thrush can also cause a white, milky plaque that does not come off with rubbing.
Choice C: Squamous cell carcinoma is a type of skin cancer that affects the squamous cells, which are flat cells that form the outer layer of the skin. Squamous cell carcinoma can occur in areas that are exposed to sun damage, such as the face, ears, lips, or neck. Squamous cell carcinoma does not affect the mouth and does not cause a white, milky plaque. Squamous cell carcinoma may cause a red, scaly, crusty, or bleeding bump or patch on the skin.
Choice D: Herpes simplex is a viral infection that affects the skin and mucous membranes, such as the mouth, lips, genitals, or eyes. Herpes simplex is transmitted by direct contact with an infected person or object. Herpes simplex does not cause a white, milky plaque. Herpes simplex may cause painful blisters or ulcers that burst and form scabs.
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