An unlicensed assistive personnel (UAP) applies a pediatric urine collection (PUC) bag on the symphysis pubis of a female infant.
Which action is most important for the practical nurse (PN) to take when checking the placement of the PUC bag?
Apply a dry diaper over the PUC bag.
Ensure the bag's adhesive is secured to the true perineum.
Calculate the infant's fluid intake.
Ask the mother when the infant previously voided.
The Correct Answer is B
Choice A rationale
Applying a dry diaper over the PUC bag is a routine step after placement but is not the most important action for checking placement. While necessary for hygiene and containing urine, it does not directly verify the correct anatomical positioning of the collection bag, which is crucial for accurate and contamination-free urine collection in infants.
Choice B rationale
Ensuring the bag's adhesive is secured to the true perineum is the most critical action. Proper placement on the true perineum (the anatomical region between the thighs, encompassing the anus and external genitalia) ensures that urine directly enters the collection bag, preventing contamination from stool or skin flora, and allowing for an accurate and sterile urine sample.
Choice C rationale
Calculating the infant's fluid intake is a separate nursing responsibility related to overall fluid balance and hydration status. It is not directly related to checking the correct placement of a pediatric urine collection bag. While fluid intake influences urine output, it does not provide information about the anatomical accuracy of the bag's application.
Choice D rationale
Asking the mother when the infant previously voided provides historical information about the infant's voiding pattern. While helpful for anticipating when the infant might void again, this information does not confirm the current, proper placement of the urine collection bag. The physical verification of adhesive placement is paramount for effective collection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
Choice A rationale
Pink-tinged urine can be a symptom of various conditions, including kidney issues or urinary tract infections. While individuals with sickle cell crisis can experience kidney complications, pink-tinged urine is not a universal or primary manifestation of a vaso-occlusive crisis. The immediate priority is pain management and infection prevention.
Choice B rationale
Palpitations, an awareness of one's own heartbeat, can be a symptom of various cardiac issues or a physiological response to stress or pain. While the heart rate is elevated (140 bpm, normal for a toddler is 90-140 bpm), this is likely secondary to the severe pain the child is experiencing and not the primary problem to be addressed.
Choice C rationale
Acute pain is a hallmark and often excruciating symptom of a sickle cell crisis, resulting from vaso-occlusion and tissue ischemia. The toddler's crying, restlessness, and aversion to touch strongly indicate severe pain, making it an immediate priority for intervention to alleviate suffering and prevent further complications.
Choice D rationale
Risk for infection is a significant concern in sickle cell disease due to functional asplenia, which compromises the immune system's ability to fight encapsulated bacteria. Despite the normal oxygen saturation, the elevated temperature (102°F or 38.8°C) in a child with sickle cell disease warrants immediate attention due to the high risk of severe infection.
Correct Answer is D
Explanation
Choice A rationale
Administering oxygen and suctioning are appropriate for respiratory distress, but turning the newborn from supine to prone every 2 hours does not prevent aspiration in tracheoesophageal fistula and may increase the risk of aspiration or worsen respiratory compromise by allowing refluxed gastric contents to enter the airway.
Choice B rationale
Offering sterile water per nipple is contraindicated in suspected tracheoesophageal fistula because it poses a significant aspiration risk, as the water will likely enter the trachea. Placing the infant in a prone position does not mitigate this aspiration risk during feeding.
Choice C rationale
Inserting an orogastric tube is appropriate, but giving feedings via gavage before confirmation is dangerous due to the risk of aspiration into the lungs if a fistula is present. Confirmation via x-ray is crucial to ensure the tube is correctly placed and feeding is safe.
Choice D rationale
Keeping the infant NPO (nothing by mouth) prevents aspiration of fluids or food into the respiratory tract, which is a major complication of tracheoesophageal fistula. Elevating the head of the crib to 30 degrees uses gravity to minimize gastroesophageal reflux and further reduce the risk of aspiration.
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