A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness.
Which of the following statements should the nurse include in the teaching?
"You should place the diaper over the strap of the harness.”
"The harness can be removed for sleeping each night.”
"You can apply lotion under the straps of the harness.”
"The harness can promote hip joint development.”
The Correct Answer is D
Choice A rationale:
The nurse should not recommend placing the diaper over the strap of the Pavlik harness. Placing the diaper over the strap can cause discomfort and may interfere with the proper function of the harness, which is designed to maintain hip joint alignment in infants with developmental hip dysplasia.
Choice B rationale:
The Pavlik harness is typically worn continuously, including during sleep. It should not be removed for sleeping each night because consistent use is essential for its effectiveness in promoting hip joint development.
Choice C rationale:
Applying lotion under the straps of the harness is not recommended. Lotions or creams can create friction and moisture, which may lead to skin irritation or discomfort for the infant. It's best to follow the healthcare provider's instructions regarding the care and maintenance of the harness.
Choice D rationale:
The correct choice is D. The nurse should include the statement that "The harness can promote hip joint development" in the teaching. This is because the Pavlik harness is used to treat developmental hip dysplasia by maintaining the hip joint in a stable position, allowing for proper development. It is important for parents to understand the purpose and benefits of the harness in order to ensure compliance and effectiveness of the treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Blacking out the line with a felt-tip pen is not an appropriate action for correcting a blank space in the nurses' notes. It can make the entry look unprofessional and may not be accepted as a proper correction.
Choice B rationale:
Leaving the space as it is within the entry is not the correct action because it does not address the blank space or provide necessary documentation. Blank spaces in documentation should be corrected appropriately.
Choice C rationale:
Drawing a horizontal line through the space and signing at the end of the line is the correct action. This is a standard practice for correcting blank spaces in documentation. It signifies that the space was intentionally left blank and has been reviewed and approved by the nurse.
Choice D rationale:
Placing the date at the beginning of the space, followed by double lines, is not a standard or recommended method for correcting blank spaces in documentation. It can lead to confusion and may not meet documentation standards.
Correct Answer is D
Explanation
Choice A rationale:
Insomnia is not typically associated with increased intracranial pressure (ICP) Instead, infants with increased ICP may exhibit signs of altered consciousness, lethargy, or increased sleepiness.
Choice B rationale:
A low-pitched cry is not a specific manifestation of increased ICP. Increased ICP in infants may cause high-pitched crying due to discomfort or irritability.
Choice C rationale:
A positive Babinski reflex is not a typical manifestation of increased ICP in infants. Instead, increased ICP may result in neurological signs such as altered level of consciousness, irritability, vomiting, and changes in vital signs.
Choice D rationale:
Bulging fontanel is the correct manifestation to expect in an infant with increased ICP. The fontanel may become tense and bulging due to increased pressure within the skull. This is a concerning sign and should be promptly reported for further evaluation and intervention.
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