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
Serous chest tube drainage is a normal finding and does not typically indicate a complication. It is usually clear or pale yellow fluid that is expected after surgery.
Choice B rationale
Chest tube drainage of 200 mL in 1 hour is excessive and should be reported to the provider. This could indicate active bleeding or other complications that require immediate attention.
Choice C rationale
Fluctuation in the water-sealed chamber, also known as tidaling, is a normal finding and indicates that the chest tube is functioning properly. It reflects changes in pressure within the pleural space during respiration.
Choice D rationale
A respiratory rate of 22/min is within the normal range for a school-age child and does not typically indicate a complication.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Blood should not be stored at room temperature for more than 30 minutes. The second unit should be stored in a blood bank refrigerator until needed.
Choice B rationale
Each unit of blood should be infused within 4 hours to reduce the risk of bacterial contamination.
Choice C rationale
RBCs should be administered using filtered IV tubing to prevent the infusion of clots and other debris.
Choice D rationale
Dextrose 5% in water should not be used during the infusion of packed RBCs as it can cause hemolysis. .
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