A nurse is planning care for an infant who has a prescription for a Pavlik harness. Which of the following actions should the nurse take?
Lengthen the harness straps weekly.
Position the diaper over the straps with each change.
Massage the skin under the straps daily.
Apply lotion to the skin beneath the straps twice daily.
The Correct Answer is C
The correct answer is Choice C
Choice A rationale: Lengthening the harness straps weekly can interfere with proper hip positioning and the effectiveness of the Pavlik harness. The straps should be adjusted only by a healthcare professional to ensure correct alignment and fit.
Choice B rationale: Positioning the diaper over the straps can lead to improper harness function and hygiene issues. The diaper should be placed under the straps to maintain the harness's positioning and effectiveness, reducing the risk of skin irritation.
Choice C rationale: Massaging the skin under the straps daily helps to promote circulation and prevent skin breakdown. Regular skin checks and massages can also help to identify any early signs of irritation or pressure sores, ensuring infant comfort and safety.
Choice D rationale: Applying lotion to the skin beneath the straps twice daily can increase the risk of skin irritation and breakdown due to moisture accumulation. It is better to keep the skin clean and dry, with occasional massages to maintain skin integrity
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Holding the child during assessments may cause distress and is not recommended for children with autism spectrum disorder.
Choice B rationale
Establishing a reward system is an effective intervention for children with autism spectrum disorder as it reinforces positive behaviors.
Choice C rationale
Maintaining extended eye contact can be uncomfortable for children with autism and is not recommended.
Choice D rationale
Engaging in cooperative play may be challenging for children with autism, and structured activities are often more beneficial. .
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
While explaining the procedure to the adolescent and their guardian is important, it is not the nurse’s primary responsibility to provide detailed explanations of the procedure. This should be done by the provider performing the procedure.
Choice B rationale
Witnessing the adolescent’s signature on the informed consent form is part of the nurse’s role, but it does not address the guardian’s lack of understanding about the procedure.
Choice C rationale
Requesting assistance from the anesthesiologist to clarify the misunderstanding is not appropriate, as the anesthesiologist may not be the best person to explain the procedure. The provider performing the procedure should be the one to provide clarification.
Choice D rationale
Notifying the provider who is scheduled to perform the procedure is the correct action. The provider is responsible for ensuring that the patient and their guardian fully understand the procedure and its risks and benefits before obtaining informed consent.
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