When preparing an adolescent for a lumbar puncture, which of the following actions should the nurse take?

Correct Answer: B

Rationale: In preparing an adolescent for a lumbar puncture, the correct action for the nurse to take is to apply topical analgesic cream to the site one hour prior to the procedure (Option B). This is because the application of topical analgesic cream helps to numb the area, reducing the pain and discomfort the adolescent may experience during the procedure. It promotes a more comfortable experience and can help alleviate anxiety in the adolescent. Option A, placing a cardiac monitor on the adolescent prior to the procedure, is incorrect as a cardiac monitor is not typically required for a lumbar puncture in this context. Option C, keeping the adolescent in a semi-Fowler's position for 4 hours following the procedure, is also incorrect as maintaining a supine position is usually recommended to prevent complications post-procedure. Option D, restricting fluids for 2 hours following the procedure, is incorrect as maintaining hydration is important to prevent complications such as post-lumbar puncture headache. In an educational context, understanding the rationale behind each action is crucial for pediatric nurses to provide safe and effective care to their patients. Teaching the importance of proper preparation, including pain management strategies like applying topical analgesic cream, helps nurses optimize the patient experience and outcomes during procedures like lumbar punctures.

Correct Answer: A

Rationale: Celiac disease is a condition where individuals are unable to digest gluten, leading to damage in the bowel cells and subsequent malabsorption. This malabsorption commonly presents with symptoms such as steatorrhea, which is characterized by foul-smelling, greasy, and bulky stools due to high fat content. Therefore, the nurse should expect steatorrhea as a clinical manifestation in clients with celiac disease.

Correct Answer: C

Rationale: The correct answer is C) Administer an analgesic to the child. Prior to hydrotherapy treatment for wound debridement in a preschooler following a burn injury, it is crucial to provide pain relief to ensure the child's comfort and cooperation during the procedure. Pain management is essential in pediatric care to reduce anxiety, promote healing, and improve overall outcomes. Option A) Apply topical antimicrobial ointment to the child's wound is incorrect as this step should have been taken earlier in the wound care process and is not specifically needed prior to hydrotherapy treatment. Option B) Place a mesh gauze dressing over the child's wound is incorrect as it does not address the immediate need for pain relief before the procedure. Option D) Initiate prophylactic antibiotic therapy for the child is incorrect as it is not indicated solely for wound debridement and does not address the immediate pain management needs of the child. In pediatric nursing, providing age-appropriate pain management is essential to ensure optimal care and positive outcomes for the child. By administering an analgesic prior to the hydrotherapy treatment, the nurse can help alleviate the child's pain and promote a more successful and comfortable procedure.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Leakage of cerebrospinal fluid. Following ventriculoperitoneal shunt placement in an infant with hydrocephalus, any leakage of cerebrospinal fluid is a critical finding that must be reported promptly. Cerebrospinal fluid leakage can lead to complications such as infection, meningitis, and shunt malfunction, which can be life-threatening for the infant. Option A) Decreased urine output is not directly related to the infant's condition post-ventriculoperitoneal shunt placement and is not as concerning as cerebrospinal fluid leakage. Option B) A temperature of 37.5 degrees C (99.5 degrees F) is within a normal range for an infant and is not a priority finding in this situation. Option C) A heart rate of 130/min is elevated but can be a common response to surgery and anesthesia in infants and may not be as urgent as identifying cerebrospinal fluid leakage. Educational context: Understanding the immediate postoperative care needs of infants with hydrocephalus who have undergone ventriculoperitoneal shunt placement is crucial for pediatric nurses. Recognizing and prioritizing critical findings such as cerebrospinal fluid leakage can help prevent complications and ensure the best outcomes for the infant. Regular assessments and prompt reporting of abnormal findings are essential in pediatric nursing care to provide safe and effective postoperative management.

Correct Answer: C

Rationale: In pediatric nursing, educating parents and guardians on home safety is crucial to prevent accidents and promote the well-being of infants. Option C, "I will keep my baby's crib away from the radiator," indicates an understanding of the teaching because it addresses the risk of burns or overheating for the infant. Placing the crib away from heat sources reduces the risk of accidental burns, ensuring a safe sleep environment for the baby. Options A, placing the baby on her stomach to sleep, and B, putting a small pillow in the crib, are incorrect as they both pose risks for sudden infant death syndrome (SIDS). Placing an infant on their stomach increases the risk of SIDS, while pillows and other soft bedding increase the risk of suffocation. Option D, using a drop-side crib, is also incorrect as drop-side cribs have been banned due to safety concerns. These cribs pose a risk of entrapment and suffocation for infants. Educationally, this question highlights the importance of educating caregivers on safe sleep practices and home safety measures to prevent common childhood injuries and accidents. It reinforces the need for evidence-based recommendations to ensure the well-being of infants.