A 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure?

Correct Answer: A

Rationale: The correct answer is A) Describe the side-lying, knees-to-chest position that must be assumed during the procedure. This is the most appropriate response because it provides essential information to prepare the child for the lumbar puncture procedure. By describing the position the child needs to be in, the nurse ensures the child understands what to expect and can cooperate better during the procedure. Option B) Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours after the procedure is incorrect because it does not address the child's immediate concerns about the procedure itself. This information is important but not as crucial as preparing the child for the procedure itself. Option C) Reassuring the child that there will be no restrictions on activity after the procedure is completed is incorrect as it does not address the child's anxiety or provide information about the procedure. Option D) Telling the child to expect loud clicking noises during the procedure that may be slightly annoying is incorrect as it may increase the child's anxiety without providing useful information to help the child cope during the procedure. Educationally, when preparing a child for a medical procedure, it is crucial to provide clear, age-appropriate information to reduce anxiety and facilitate cooperation. Describing the procedure in a simple and understandable way helps build trust between the child and healthcare provider, leading to a more positive experience for the child.

Correct Answer: D

Rationale: The best response for the nurse in this situation is to help the child understand that the separation is temporary. Waving bye-bye to mommy can be reassuring to the child and make the separation process easier. It acknowledges the child's feelings while providing a positive and comforting interaction.

Correct Answer: C

Rationale: Providing two breaths that make the chest rise is the correct action in this situation. This helps to deliver oxygen to the infant's lungs and body, which is crucial in a situation where the infant is not breathing. Chest rise indicates successful ventilation, and it is an essential step in pediatric resuscitation, especially for infants.

Correct Answer: B

Rationale: In this scenario, the correct intervention is option B: Notify the healthcare provider of the passage of brown stool. This action is crucial because the passage of brown stool in an infant with intussusception may indicate a resolution of the condition, potentially eliminating the need for the scheduled procedure. Option A, instructing the parents that the infant needs to be NPO (nothing by mouth), is incorrect because the passage of stool suggests that the obstruction may have resolved, and unnecessarily withholding nutrition could be detrimental to the infant's well-being. Option C, obtaining a stool specimen for laboratory analysis, is not the priority in this situation as the focus should be on the clinical implications of the passage of stool. Option D, asking the parents about recent changes in the infant's diet, is not the most appropriate action at this time as the passage of stool is a significant clinical finding that requires immediate attention from the healthcare provider. For educational context, understanding the signs and symptoms of intussusception, including the significance of stool passage in this condition, is essential for pediatric nurses to provide safe and effective care to infants. Timely communication with the healthcare team is critical in ensuring appropriate management and positive outcomes for pediatric patients.

Correct Answer: A

Rationale: The correct answer is A) Describe the side-lying, knees to chest position that must be assumed during the procedure. This is the most appropriate information to provide to a 2-year-old child before a lumbar puncture for several reasons. Firstly, children at this age have limited cognitive abilities and may not fully understand complex explanations or instructions. Describing the position in a simple and concrete manner helps the child visualize what will happen during the procedure, reducing anxiety and fear. Additionally, using age-appropriate language and providing a clear expectation of what is expected can help the child cooperate better during the procedure. Option B) Tell the child to expect loud clicking noises during the procedure that may be slightly annoying is incorrect because it introduces a potential negative element that may increase the child's anxiety. It is important to focus on reassuring and preparing the child rather than introducing potentially distressing details. Option C) Reassure the child that there will be no restrictions on activity after the procedure is completed is incorrect because it does not address the immediate concerns or preparation needed for the procedure itself. While it is important to provide reassurance, information about the procedure should take precedence. Option D) Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours after the procedure is incorrect because it provides information that may not be developmentally appropriate or relevant for a 2-year-old child. This level of detail regarding fluid restrictions is more suitable for older children or adults who can understand and follow such instructions.