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.

Answer and Explanation

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 D

Explanation

The correct answer is choice d. Measure the blood pressure twice more during the visit and calculate the average of the three readings.

Choice A rationale:

Referring the child to the healthcare provider and scheduling a blood pressure evaluation in two weeks is not the immediate next step. It is important to confirm the elevated blood pressure reading during the same visit before making any referrals.

Choice B rationale:

Performing a comprehensive assessment and avoiding repeated blood pressure measurements is not appropriate. Repeated measurements are necessary to confirm the initial finding of elevated blood pressure.

Choice C rationale:

Taking the child’s blood pressure three times and recording the highest reading is not the best practice. The highest reading might not be representative of the child’s true blood pressure.

Choice D rationale:

Measuring the blood pressure twice more during the visit and calculating the average of the three readings is the correct approach. This method helps to ensure that the blood pressure reading is accurate and not influenced by temporary factors such as anxiety or movement.

A. Fever 101.0° F (38.3°C) B. Barking cough, worse at night C. Frequent crying during nursing D. Difficulty swallowing secretions .

Correct Answer is D

Explanation

Choice A rationale
While a fever could indicate an infection or other illness, it is not the most concerning symptom in a child with croup. Croup is primarily a respiratory condition, and symptoms related to breathing difficulties are generally of greater concern.
Choice B rationale
A barking cough is a common symptom of croup, but it is not typically the primary concern for a telephone triage nurse. While it can be distressing, it is not usually a sign of a severe or life-threatening condition.
Choice C rationale
Frequent crying during nursing could indicate discomfort or distress, but it is not the most concerning symptom in a child with croup. Croup primarily affects the respiratory system, and symptoms related to breathing difficulties are generally of greater concern.
Choice D rationale
Difficulty swallowing secretions is the most concerning symptom in a child with croup. This could indicate severe swelling of the airway, which could potentially lead to breathing difficulties and require immediate medical attention.

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When initiating a peripheral intravenous (IV) infusion on an infant, what action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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