The nurse has an order to administer a rectal suppository to a 3-month-old child. In addition to lubricating the suppository, which intervention will help assure appropriate administration of the medication?
Holding the buttocks tightly together for 1 to 2 minutes after insertion.
Pre-warming the suppository in the hand for 10 to 20 seconds.
Using the index finger to insert the suppository into the rectum.
Placing the child on the abdomen for insertion of the suppository.
The Correct Answer is A
Choice A reason: Holding the buttocks together for 1-2 minutes after suppository insertion prevents expulsion, ensuring the medication is absorbed in a 3-month-old. This aligns with pediatric medication administration protocols, making it the correct intervention to assure effective delivery of the rectal suppository in this infant.
Choice B reason: Pre-warming the suppository is not standard, as it may soften excessively, complicating insertion. Holding the buttocks ensures retention, directly impacting absorption, making this less effective and incorrect compared to the critical step of preventing expulsion in a 3-month-old during suppository administration.
Choice C reason: Using the index finger is inappropriate for an infant, as the pinky finger is safer for their small rectum. Holding the buttocks ensures medication retention, making this unsafe and incorrect compared to the prioritized intervention for effective suppository administration in a 3-month-old child.
Choice D reason: Placing the child on the abdomen may aid positioning but does not ensure suppository retention like holding the buttocks. Retention is critical for absorption, making this less essential and incorrect compared to the direct intervention of securing the suppository in place post-insertion for the infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Having the nurse do everything may disrupt the toddler’s trust in parents, hindering adaptation. Following home routines provides familiarity, making this counterproductive and incorrect compared to maintaining continuity to ease the toddler’s transition from home to the hospital environment.
Choice B reason: Telling a toddler expectations assumes cognitive understanding beyond their developmental stage, potentially increasing anxiety. Home routines offer comfort, making this less effective and incorrect compared to the nurse’s focus on familiarity to support the toddler’s hospital adaptation process.
Choice C reason: Following home routines maintains familiarity, reducing stress and aiding a toddler’s adaptation to the hospital. This aligns with pediatric psychosocial care principles, making it the most beneficial action for the nurse to implement to ease the toddler’s transition from home to hospital.
Choice D reason: Allowing a toddler to dictate actions disregards necessary medical routines, potentially compromising care and safety. Home routines provide structure, making this impractical and incorrect compared to the nurse’s role in maintaining familiarity to support the toddler’s hospital adaptation.
Correct Answer is B
Explanation
Choice A reason: Imitating adult behavior to be nice does not explain the child’s withdrawal and concern when the father is away. Fear of loss better accounts for these anxiety-driven behaviors post-accident, making this less fitting and incorrect for the child’s emotional response to the traumatic event.
Choice B reason: The child’s withdrawal and concern when the father is away suggest fear of losing him after the accident, a common reaction in young children. This aligns with pediatric psychology evidence on trauma response, making it the correct factor explaining the child’s behavior in this context.
Choice C reason: Fear of personal injury is less likely than fear of losing the father, given the child’s focus on the father’s absence. Withdrawal reflects attachment anxiety, not self-protection, making this less accurate and incorrect compared to the loss-related emotional response observed in the child.
Choice D reason: Believing he caused the accident is possible but less supported without evidence of guilt statements. Fear of loss better explains the child’s withdrawal and concern for the father’s absence, making this speculative and incorrect for the primary behavioral factor affecting the 5-year-old.
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