A nurse is providing peritoneal dialysis to a child and observes there is minimal dialysate outflow at the end of the outflow time. Which of the following actions should the nurse take?
Increase the dwell time during the next dialysis infusion.
Instruct the child to change position.
Increase oral fluid intake.
Assess for a bruit at the site of the peritoneal catheter.
The Correct Answer is B
Choice A rationale
Increasing the dwell time during the next dialysis infusion is not appropriate. The issue is with the outflow, not the dwell time. Increasing the dwell time could exacerbate the problem.
Choice B rationale
Instructing the child to change position is correct. Changing position can help facilitate the drainage of dialysate by allowing gravity to assist in the outflow process.
Choice C rationale
Increasing oral fluid intake is not relevant to the issue of minimal dialysate outflow. The problem lies with the mechanical process of dialysis, not fluid intake.
Choice D rationale
Assessing for a bruit at the site of the peritoneal catheter is not directly related to resolving minimal dialysate outflow. A bruit indicates blood flow through a vascular access, not the peritoneal catheter.
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Correct Answer is A
Explanation
Choice A rationale
The presence of the Doll’s eye reflex (oculocephalic reflex) beyond the newborn period is abnormal and should be reported. This reflex should disappear by 2-3 months of age. Its persistence may indicate neurological issues.
Choice B rationale
No head lag when pulled to a sitting position is a normal finding in a 4-month-old infant. By this age, infants typically have developed enough neck muscle strength to hold their head steady.
Choice C rationale
The presence of tears when crying is a normal finding in a 4-month-old infant. Tear production usually begins around 2-3 months of age.
Choice D rationale
A positive Babinski reflex is normal in infants up to 2 years old. It is an expected finding and does not require notification to the provider.
Correct Answer is B
Explanation
Choice A rationale
Holding the child during assessments may cause distress and is not recommended for children with autism spectrum disorder.
Choice B rationale
Establishing a reward system is an effective intervention for children with autism spectrum disorder as it reinforces positive behaviors.
Choice C rationale
Maintaining extended eye contact can be uncomfortable for children with autism and is not recommended.
Choice D rationale
Engaging in cooperative play may be challenging for children with autism, and structured activities are often more beneficial.