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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A: This instruction is correct, as iron supplements can cause a change in the color and consistency of stools, making them dark, green, or black. This is not a sign of bleeding or infection, but a normal side effect of iron therapy. The parents should be informed of this possibility and reassured that it is harmless.

Choice B: This instruction is incorrect, as iron supplements should not be administered at bedtime, but rather one hour before or two hours after meals. This is because iron absorption is reduced by food, especially dairy products, antacids, or calcium supplements. The parents should be instructed to give the medication on an empty stomach or with a small amount of food if it causes nausea.

Choice C: This instruction is incorrect, as iron supplements should not be given with milk, as milk contains calcium, which can interfere with iron absorption and reduce its eﬀectiveness. The parents should be instructed to avoid giving milk or other dairy products within two hours of the medication.

Choice D: This instruction is incorrect, as iron supplements should not be administered at mealtimes, but rather one hour before or two hours after meals. This is because iron absorption is reduced by food, especially dairy products, antacids, or calcium supplements. The parents should be instructed to give the medication on an empty stomach or with a small amount of food if it causes nausea.

A. "I'm glad that my child's ostomy is only temporary." B. "I want to learn how to empty my child's urinary catheter bag." C. "I want to learn how to use my child's feeding tube as soon as possible." D. "I'm glad my child will have normal bowel movements now."

Correct Answer is A

Explanation

Choice A: An ostomy is a surgical opening in the abdomen that allows stool to pass out of the body. A child who has Hirschsprung disease, which is a condition that causes a blockage of the large intestine due to a lack of nerve cells, may need an ostomy to relieve the obstruction and prevent complications. The ostomy is usually temporary and can be reversed after the aﬀected part of the intestine is removed or repaired. This statement indicates an understanding of the teaching, as the parent knows that the ostomy is not permanent.

Choice B: A urinary catheter is a tube that drains urine from the bladder. A child who has Hirschsprung disease does not need a urinary catheter, as their condition does not affect their urinary system. This statement indicates a lack of understanding of the teaching, as the parent is confused about the type of surgery or device that their child will have.

Choice C: A feeding tube is a tube that delivers nutrition directly into the stomach or small intestine. A child who has Hirschsprung disease may need a feeding tube if they have severe malnutrition, dehydration, or infection due to their condition. However, this is not always necessary and depends on the individual case and the surgeon's preference.
This statement indicates a lack of understanding of the teaching, as the parent assumes that their child will need a feeding tube without knowing the specific plan.

Choice D: A child who has Hirschsprung disease will not have normal bowel movements after the initial surgery, as they will still have an ostomy that bypasses their large intestine. They will need another surgery to reconnect their intestine and restore their bowel function. This statement indicates a lack of understanding of the teaching, as the parent has unrealistic expectations about the outcome of the surgery.

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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?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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