A nurse is preparing to obtain a urine sample from a 7-month-old client. Which of the following collection methods should the nurse identify as yielding the most reliable urinalysis and urine culture results?
Clean-catch
Straight catheterization
Suprapubic aspiration
Urine collection bag
The Correct Answer is B
A. Clean-catch samples are difficult to obtain in infants and may yield contaminated results.
B. Straight catheterization is the most reliable method for obtaining a sterile urine sample in infants, providing accurate results for both urinalysis and urine culture.
C. Suprapubic aspiration is another sterile method but is less commonly performed than catheterization.
D. A urine collection bag can be contaminated and is less reliable for culture or urinalysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
A. While the Babinski reflex can be assessed in older children, it is not an appropriate reflex to assess in an 11-month-old infant. Infants typically show a different reflex pattern, and the Babinski reflex may not provide meaningful insight in this age group. The focus should be on vital neurological signs like pupil reaction and fontanel assessment.
B. The infant's pupils should be regularly monitored for changes, as a decrease in pupil reaction or size could indicate increased intracranial pressure (ICP), which may be related to the subdural hematoma. This is a critical assessment to identify neurological changes.
C. The infant’s difficulty waking could indicate a change in neurological status, potentially due to increased ICP or other complications from the subdural hematoma. Feeding should not be encouraged until the infant is fully alert and stable to avoid the risk of aspiration or choking. Instead, the infant's neurological status should be assessed further.
D. In infants, the fontanels are a key indicator of increased intracranial pressure. A bulging fontanel can indicate rising ICP, which requires immediate intervention. This should be checked regularly in cases of head trauma.
E. Since the infant has fallen from a height (a flight of stairs), spine stabilization is necessary until spinal injury can be ruled out. The infant should be moved cautiously, and spine precautions should be maintained to prevent further injury.
F. Monitoring the head circumference is essential for detecting any signs of increased ICP. A sudden increase in head circumference may suggest worsening edema or hemorrhage, especially in the setting of a subdural hematoma.
Correct Answer is A
Explanation
A. The child's urine output is 160 mL over 8 hours, which is within the normal expected output for the child (roughly 1-2 mL/kg/hr). Therefore, continuing to monitor without taking further action would be appropriate given the client’s urine output is adequate.
B. Providing oral rehydration fluids may not address the underlying cause of oliguria.
C. Performing a bladder scan may help assess for retention, but the primary action is to notify the provider.
D. The client’s urine output is within the normal ranges hence the correct action is to continue monitoring.
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