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. Which is considered a block to effective communication?

Correct answer: B

Rationale: Using clichés is a communication block because it can come across as dismissive or insincere, hindering meaningful dialogue.

3. At which age can most infants sit steadily unsupported?

Correct answer: C

Rationale: Most infants can sit steadily without support by 8 months, indicating advanced gross motor skill development.

4. What signs and symptoms are indicative of a urinary tract disorder in the infancy period (1-24 months)? (Select all that apply.)

Correct answer: A

Rationale: In infants, urinary tract disorders may present with poor feeding, hypothermia, and frequent urination. Pallor can be associated with other conditions but is less specific to urinary tract disorders.

5. The nurse is caring for a child with acute renal failure. What laboratory findings should the nurse expect to find? (Select all that apply.)

Correct answer: C

Rationale: In acute renal failure, laboratory findings typically include hyperkalemia, hyponatremia, and elevated blood urea nitrogen (BUN) levels due to the kidneys' inability to excrete waste and balance electrolytes. Metabolic alkalosis is less common, with metabolic acidosis being more typical.

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