A 3-year-old child is brought to the emergency room with a head injury after falling from a height. The child is unconscious and not breathing. What is the nurse's immediate action?

Administering rescue breaths

Checking for a pulse

Initiating chest compressions

Initiating abdominal thrusts

Answer and Explanation

The Correct Answer is A

A. Administering rescue breaths is the immediate action for an unconscious child who is not breathing. CPR should be initiated immediately.

B. Checking for a pulse can be done after initiating rescue breaths and chest compressions.

C. Initiating chest compressions is part of CPR but should be preceded by rescue breaths.

D. Initiating abdominal thrusts is used for foreign body airway obstruction, not for an unconscious child with a head injury and respiratory distress.

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Correct Answer is C

Explanation

A. Febrile seizure presents with sudden convulsions and fever in children and does not cause pale, lethargic symptoms with chest pain and tachycardia.

B. Hypoglycemia can cause weakness and altered mental status, but it does not typically present with chest pain, tachycardia, and weak pulses.

C. Cardiogenic shock, often seen in children with heart disease, can present with pale, lethargic appearance, chest pain, tachycardia, and weak pulses due to poor cardiac output.

D. Foreign body aspiration can cause sudden respiratory distress and choking, but it does not present with chest pain, pale appearance, tachycardia, and weak pulses.

A. Offering oral rehydration solution (ORS) B. Administering intravenous fluids C. Monitoring the infant's vital signs D. Obtaining a urine sample for analysis

Correct Answer is B

Explanation

A. Offering oral rehydration solution (ORS) may not be effective for severe dehydration in an infant who is unable to drink or tolerate oral fluids.

B. Administering intravenous fluids is the priority intervention for a severely dehydrated infant to restore fluid balance and prevent complications.

C. Monitoring vital signs is important but does not address the immediate need for fluid replacement in severe dehydration.

D. Obtaining a urine sample is not the priority; intravenous fluids should be initiated promptly in a severely dehydrated infant.

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A 3-year-old child is brought to the emergency room with a head injury after falling from a height. The child is unconscious and not breathing. What is the nurse's immediate action?

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