A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. Which action should the nurse implement first?

Type and cross for possible transfusion.

Initiate an IV site and begin infusing normal saline.

Monitor the child's vital signs frequently.

Apply ice pack and compression dressing to knee.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Typing and crossmatching for a possible transfusion is not the immediate priority for a child with hemophilia who has a swollen knee. While a transfusion might be necessary if there is significant bleeding, initial management should focus on controlling the bleeding and minimizing joint damage.

Choice B rationale

Initiating an IV site and beginning infusing normal saline is not the first action to take in this scenario. While IV access might be needed later, immediate measures should focus on controlling bleeding and reducing swelling to prevent further damage to the knee joint.

Choice C rationale

Monitoring the child's vital signs frequently is important, but it is not the first action to take. The priority is to control the bleeding and reduce the swelling, which are the immediate concerns in this situation.

Choice D rationale

Applying an ice pack and compression dressing to the knee is the first action to take. This helps to control bleeding, reduce swelling, and minimize joint damage. This is a crucial step in managing hemophilia-related injuries and should be done immediately upon recognizing a swollen joint.

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Correct Answer is A

Explanation

Choice A rationale

Placing the client in Trendelenburg position is the first action as it helps to relieve pressure off the umbilical cord by using gravity to shift the fetus away from the pelvis. This position helps to prevent cord compression and maintain blood flow to the fetus.

Choice B rationale

Notifying the operating room team is important but should be done after immediately addressing the umbilical cord prolapse to prevent fetal hypoxia. Initial physical intervention takes priority.

Choice C rationale

Administering oxygen via face mask is beneficial for the mother and fetus but is not the immediate first action. Positioning the client to relieve pressure off the umbilical cord is more urgent.

Choice D rationale

Administering a fluid bolus of 500 mL can help maintain maternal blood pressure, but it is not the first action. The priority is to reposition the client to prevent cord compression.

A. Ventricular septal defect (VSD) has audible murmurs. B. Patent ductus arteriosus is fatigued after feeding C. Coarctation of aorta has an elevated blood pressure in the upper extremity. D. Tetralogy of Fallot (TOF) with hypercyanotic (Tet) spells is crying.

Correct Answer is D

Explanation

Choice A rationale

An audible murmur in a neonate with a ventricular septal defect (VSD) is a common finding and does not typically require immediate intervention. While it indicates a cardiac anomaly, it is not an emergency.

Choice B rationale

Fatigue after feedings in a neonate with patent ductus arteriosus (PDA) is a sign of increased cardiac workload, but it does not indicate an immediate life-threatening situation. It requires monitoring but not urgent intervention.

Choice C rationale

Elevated blood pressure in the upper extremity in a neonate with coarctation of the aorta is a concerning finding that indicates a narrowing of the aorta. While it requires prompt evaluation and management, it may not be as immediately critical as a hypercyanotic spell.

Choice D rationale

A neonate with Tetralogy of Fallot (TOF) experiencing hypercyanotic (Tet) spells and crying indicates a severe decrease in oxygenation and is an emergency. This condition requires immediate intervention to improve oxygenation and prevent complications such as brain damage or death. .

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A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. Which action should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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