the nurse is caring for a very low birth weight vlbw infant with a peripheral intravenous infusion what nursing considerations regarding infiltration
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Nursing Elites

ATI RN

Nursing Care of Children ATI

1. The nurse is caring for a very low-birth-weight (VLBW) infant with a peripheral intravenous infusion. What nursing considerations regarding infiltration should be included in planning IV care?

Correct answer: C

Rationale: Hypertonic solutions can damage tissues if they leak from the vein due to infiltration. It is crucial to monitor for this complication to prevent severe tissue damage. Infiltration is not solely related to the activity level of VLBW infants; it can occur due to various reasons such as vein condition, catheter placement, and fluid type. Continuous infusion pumps may not always detect infiltration, as they typically alarm for pressure changes but not all infiltration instances. Checking the infusion site regularly, preferably hourly, is essential to prevent complications like tissue damage from extravasations, fluid overload, and dehydration.

2. What is an appropriate nursing intervention for a child with minimal change nephrotic syndrome (MCNS) who has scrotal edema?

Correct answer: C

Rationale: Elevating the scrotum with a rolled washcloth helps reduce edema by promoting fluid drainage. Ice packs are not recommended due to the risk of frostbite, and warm moist packs are not typically used for this purpose. An upright position does not specifically address the edema.

3. Which distraction technique should be used for an adolescent child during a painful procedure?

Correct answer: B

Rationale: The correct answer is B: Guided imagery. Guided imagery is an effective distraction technique for adolescents as it helps them focus on positive mental images instead of the pain. This technique can be a powerful tool in managing pain and anxiety during procedures. Blowing bubbles (choice A) may be more suitable for younger children as it can engage them visually and help distract them. EMLA cream (choice C) is a topical anesthetic and not a distraction technique. Sucrose solution (choice D) is used for pain relief in infants, not typically for adolescents undergoing painful procedures.

4. Which is a complication that can occur after abdominal surgery if pain is not managed?

Correct answer: A

Rationale: Poorly managed pain after abdominal surgery can lead to complications like atelectasis due to shallow breathing, which may occur if the child avoids deep breaths because of pain.

5. Chemicals, agents, or factors that cause physical defects in the developing embryo and are most harmful during organogenesis are:

Correct answer: A

Rationale: Teratogens are substances that can cause congenital abnormalities, especially during the first trimester when organogenesis occurs. Choice A, Teratogens, is the correct answer as it specifically refers to substances that cause physical defects in the developing embryo. Choices B, Heterozygous, C, Inborn errors, and D, Multifactorial, are incorrect as they do not directly relate to substances that cause physical defects in embryos during organogenesis.

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