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 B
Explanation
Choice A reason: Complying with a babysitter despite being upset shows adaptability, not initiative, which involves self-directed tasks. Attempting to clean cereal reflects proactive behavior, making this less indicative and incorrect compared to an activity demonstrating the 4-year-old’s initiative in the developmental assessment.
Choice B reason: Trying to sweep spilled cereal and crying when failing demonstrates initiative, as the 4-year-old independently attempts a task, a hallmark of Erikson’s initiative stage. This aligns with pediatric developmental milestones, making it the correct activity to document for assessing the child’s growth and development status.
Choice C reason: Refusing to hold hands while crossing the street indicates defiance, not initiative, which involves purposeful self-started activities. Cleaning cereal better reflects initiative, making this incorrect, as it shows autonomy rather than the proactive behavior expected in the initiative stage of development.
Choice D reason: Blaming a broken dish on a fictional friend shows guilt avoidance, not initiative, which involves taking on tasks independently. Attempting a cleanup task is more indicative, making this incorrect compared to the proactive behavior of sweeping cereal in the 4-year-old’s developmental assessment.
Correct Answer is A
Explanation
Choice A reason: At birth, the infant’s right and left ventricles are nearly equal in size due to fetal circulation demands. This aligns with pediatric cardiology, making it the correct statement demonstrating understanding of the newborn’s cardiovascular system as discussed in the nurses’ review session.
Choice B reason: The heart matures earlier, with adult-like function by early childhood, not 8-10 years. Equal ventricle size at birth is accurate, making this incorrect, as it overestimates the timeline for cardiovascular maturation in the nurse’s understanding of the child’s heart development.
Choice C reason: Heart rate typically increases with fever in children, not decreases, due to metabolic demands. Equal ventricle size at birth is correct, making this inaccurate and incorrect compared to the true statement about the infant’s cardiovascular system in the nurses’ review.
Choice D reason: The left ventricle grows slightly larger but not twice the right’s size by 5-6 years. Equal ventricles at birth is accurate, making this incorrect, as it exaggerates ventricular growth in the nurse’s understanding of the child’s cardiovascular system development.
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