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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: A 3-year-old child is not developmentally ready to descend stairs by placing both feet on each step and holding on to the railing. A 3-year-old child can walk up stairs alternating feet with one hand held by an adult or on the railing. A 3-year-old child can also walk down stairs placing both feet on each step with one hand held by an adult.
Choice B: A 4-year-old child is developmentally able to descend stairs by placing both feet on each step and holding on to the railing. A 4-year-old child can also walk up stairs alternating feet without assistance.
Choice C: A 5-year-old child is developmentally more advanced than descending stairs by placing both feet on each step and holding on to the railing. A 5-year-old child can walk up and down stairs alternating feet without assistance.
Choice D: A 6-year-old child is developmentally more advanced than descending stairs by placing both feet on each step and holding on to the railing. A 6-year-old child can walk up and down stairs alternating feet without assistance and can also hop and skip on one foot.
Correct Answer is C
Explanation
Choice A: Smiling when a parent appears is not a manifestation of cerebral palsy, but rather a normal developmental milestone that indicates social and emotional development. An 8-month-old infant should be able to smile spontaneously and responsively at familiar people.
Choice B: Using a pincer grasp to pick up a toy is not a manifestation of cerebral palsy, but rather a normal developmental milestone that indicates fine motor development. An 8-month-old infant should be able to use their thumb and index finger to pick up small objects.
Choice C: Sitting with pillow props, cannot sit independently is a manifestation of cerebral palsy, which is a condition that causes impaired movement and posture due to brain damage or abnormal development. An 8-month-old infant should be able to sit without support and maintain balance. Sitting with pillow props, cannot sit independently indicates poor muscle tone, strength, or coordination.
Choice D: Tracking an object with eyes is not a manifestation of cerebral palsy, but rather a normal developmental milestone that indicates visual development. An 8-month-old infant should be able to follow an object or person with their eyes in all directions.
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