A nurse is preparing to obtain a urine specimen from a 5-month-old infant using a urine collection bag. Which of the following actions should the nurse take?
Attach the bag first to the perineum, then to the skin above the urethra.
Remove the bag 1 hr after the infant voids.
Place absorbent cotton balls inside the bag.
Apply petroleum jelly to the perineum before applying the bag.
The Correct Answer is A
A. "Attach the bag first to the perineum, then to the skin above the urethra." Proper technique involves first securing the collection bag to the perineum to ensure a snug fit, then pressing it firmly to the surrounding skin to prevent leaks.
B. "Remove the bag 1 hr after the infant voids." The bag should be removed as soon as sufficient urine is collected to avoid contamination or leakage.
C. "Place absorbent cotton balls inside the bag." Absorbent materials would absorb the urine, making it difficult to retrieve an adequate sample for testing.
D. "Apply petroleum jelly to the perineum before applying the bag." Petroleum jelly could prevent the bag from adhering properly, leading to leakage or contamination.
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Related Questions
Correct Answer is B
Explanation
A. "Perform a sterile dressing change 8 hr after the procedure." The initial dressing should be left in place for at least 24 hours, and any dressing changes should be performed per facility protocol.
B. "Keep the affected extremity straight for 4 hr." After a femoral venous cardiac catheterization, the child should keep the affected extremity straight for about 4 to 6 hours to prevent bleeding or hematoma formation at the insertion site.
C. "Assess the pulses above the catheterization site." The pulses below the site (distal pulses) should be assessed, not above. This is important to check for adequate circulation and potential complications such as clot formation or arterial obstruction.
D. "Maintain NPO status for 24 hr following the procedure." The child should typically resume oral intake as soon as they are fully awake and able to tolerate fluids, usually within a few hours post-procedure.
Correct Answer is A
Explanation
A. "Lifts head 45° when lying prone." By 2 months of age, infants begin lifting their heads about 45 degrees while on their stomachs, which is an early sign of developing neck and upper body strength.
B. "Rolls over from back to abdomen." Rolling from back to abdomen typically occurs around 6 months of age.
C. "No head lag when pulled into a sitting position." Head lag is still present at 2 months, but it gradually disappears by 4 months as neck muscles strengthen.
D. "Rolls over from abdomen to back." Rolling from abdomen to back typically occurs around 4 months of age, followed by rolling from back to abdomen at about 6 months.
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