When initiating a peripheral intravenous (IV) infusion on an infant, what action should the nurse take?
Apply soft restraints to all four extremities.
Assess the dorsal surface of the feet for an IV site.
Instruct parents to sing or croon to the infant.
Select a site that is least restrictive to the infant.
The Correct Answer is D
Choice A rationale
Applying soft restraints to all four extremities of an infant is not typically recommended when initiating a peripheral intravenous (IV) infusion. Restraints can cause distress and may not be necessary for the procedure.
Choice B rationale
While the dorsal surface of the feet can be used as an IV site, it is not typically the first choice for infants. The veins in the feet can be difficult to access and the location can be inconvenient for the infant.
Choice C rationale
Instructing parents to sing or croon to the infant can be comforting and may help soothe the infant during the procedure. However, this action alone does not directly facilitate the successful initiation of an IV infusion.
Choice D rationale
Selecting a site that is least restrictive to the infant is the most appropriate action when initiating a peripheral IV infusion. This can make the procedure less distressing for the infant and allow for easier movement after the IV is in place.
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Correct Answer is B
Explanation
Choice A rationale
While it’s true that overstimulation can sometimes trigger seizures in children with certain neurological conditions, it’s not typically a trigger for febrile seizures. Febrile seizures are caused by a rapid increase in body temperature, often due to an infection.
Choice B rationale
Febrile seizures are most common in young children between the ages of 6 months and 5 years. As children grow older, they are less likely to have febrile seizures. Most children outgrow febrile seizures by the time they are 5 years old.
Choice C rationale
While it’s important to try to reduce a child’s fever, a sponge bath is not likely to prevent a febrile seizure. Febrile seizures are triggered by a rapid increase in body temperature, not the absolute value of the temperature.
Choice D rationale
The use of ibuprofen or other fever-reducing medications is not typically recommended as a way to prevent febrile seizures. These medications can help make the child more comfortable by reducing fever, but they do not prevent febrile seizures.
Correct Answer is C
Explanation
The correct answer is: C
Choice A reason: Comparing the child’s vital signs over the past three weeks could provide data on any changes in his physical health status. However, without additional context, this information alone may not be sufficient to determine the cause of his symptoms. Vital signs are typically within the following ranges for a healthy 10-year-old: temperature 97.8°F to 99.1°F (36.5°C to 37.3°C), pulse 70 to 110 beats per minute, respirations 17 to 22 breaths per minute, and blood pressure 90/60 mmHg to 120/80 mmHg.
Choice B reason: Counseling the parents to pay more attention to the child might be helpful if the child’s symptoms are due to emotional neglect or lack of parental involvement. However, this intervention assumes that the parents are not attentive without evidence and does not directly address the child’s reported symptoms.
Choice C reason: Asking the boy to describe a typical day at school is a non-invasive way to gather more information about potential stressors or issues that could be contributing to his symptoms. This approach can help identify if the symptoms are related to school environment, bullying, academic pressure, or other psychosocial factors.
Choice D reason: Conducting a complete neurological assessment would be appropriate if there were specific indications of neurological issues. Since the boy’s symptoms are non-specific and could be related to a variety of causes, including stress or anxiety, a neurological assessment might not be the most immediate step without further evidence suggesting a neurological cause.
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