While assisting with a lumbar puncture procedure on an infant or small child, the nurse should do which of the following actions?
Have the patient in a clean diaper to avoid contamination of the site.
Monitor the patient's cardiorespiratory status at all times.
Position the patient in the prone position with the head to the left.
Start an intravenous line to facilitate the use of conscious sedation.
The Correct Answer is B
Choice A rationale
Having the patient in a clean diaper is a general standard of care, but it is not the primary nursing action during a lumbar puncture (LP) procedure; sterile technique for the procedure site is paramount to prevent infection. The crucial nursing role is safely maintaining the necessary positioning and continuously monitoring the child's physiological status during the invasive procedure.
Choice B rationale
Continuous monitoring of the patient's cardiorespiratory status (heart rate, respiratory rate, oxygen saturation) is the most critical nursing action during an LP, especially in infants and small children who are commonly held in a tightly flexed, side-lying position. This positioning can compromise ventilation, and changes in intracranial pressure may also affect vital signs.
Choice C rationale
The correct position for a lumbar puncture is usually the side-lying position with the back fully rounded (fetal position) to maximize the space between the vertebrae, or occasionally a sitting position, allowing the provider access to the L3-L4 or L4-L5 interspaces. The prone position is not used as it prevents access to the lumbar area for the procedure.
Choice D rationale
While conscious sedation or analgesia is frequently used to minimize movement and discomfort during an LP in children, starting an IV line is not always necessary if a quick, successful procedure is anticipated without sedation, or if alternative routes for sedation are used. The most essential action is the immediate safety and monitoring of the child's vital functions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Cerebrospinal fluid (CSF) appearing cloudy or turbid is highly consistent with bacterial meningitis because the high concentration of white blood cells (pleocytosis), specifically neutrophils, and bacteria present in the CSF cause the fluid to lose its normal clear, colorless appearance. This visual change is a strong immediate indicator of severe infection.
Choice B rationale
In bacterial meningitis, the large accumulation of exudate, inflammation, and increased vascular permeability within the central nervous system usually leads to increased CSF production and decreased reabsorption, resulting in elevated or increased CSF pressure, not decreased pressure. Decreased pressure is rarely associated with acute bacterial infection.
Choice C rationale
An analysis consistent with bacterial meningitis typically shows a significantly elevated number of leukocytes (pleocytosis), especially polymorphonuclear neutrophils, reflecting the body's aggressive inflammatory response to the bacterial invasion. Few leukocytes (a normal range is 0-5 mononuclear cells/mm³) would be inconsistent with a bacterial infection.
Choice D rationale
Bacterial meningitis is characterized by bacteria consuming glucose for energy, leading to a markedly decreased CSF glucose level (hypoglycorrhachia), which is often less than 40 mg/dL or less than two-thirds of the concurrent blood glucose level. An increased glucose level in the CSF is usually not a finding in this condition.
Correct Answer is C
Explanation
Choice A rationale
A respiratory rate of 50 breaths/minute falls within the expected normal range for a healthy full-termnewborn, which is typically 30 to 60 breaths/minute. Therefore, this finding alone does not indicate respiratory distress, which is usually signaled by rates consistently below 30 or above 60. Tachypnea (rate > 60) is a more common sign of distress, reflecting the infant's attempt to improve oxygenation.
Choice B rationale
Acrocyanosis, which is the blueness of the hands and feet, is a common and usually transient finding in newborns due to sluggish peripheral circulation and vasomotor instability. It is considered a normal finding in the first 24 to 48 hours of life. Central cyanosis, which involves the mucous membranes and trunk, is a more critical sign of inadequate oxygenation and severe respiratory distress.
Choice C rationale
Asymmetrical chest movement, often referred to as paradoxical breathing, occurs when one side of the chest moves differently from the other during respiration. This is a significant abnormal finding that may indicate a condition like pneumothorax, diaphragmatic hernia, or atelectasis, all of which compromise effective lung expansion and gas exchange, leading to respiratory distress.
Choice D rationale
Short periods of apnea, defined as cessation of breathing lasting less than 15 seconds, are considered a normal variation in a newborn's breathing pattern, known as periodic breathing. Apnea lasting 15 seconds or more, or any apnea accompanied by bradycardia or cyanosis, is a concerning sign and would alert the nurse to potential respiratory or central nervous system issues.
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