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

Collecting a urine sample to screen for protein is essential as proteinuria is a key indicator of preeclampsia, a condition characterized by high blood pressure and potential organ damage during pregnancy. Early detection is vital to manage the condition and prevent complications.

Choice B rationale

Asking about a history of delivering large babies (macrosomia) is not immediately relevant to the current symptoms of headache and elevated blood pressure, which are more indicative of hypertensive disorders rather than previous birth weights.

Choice C rationale

Examining the client for pedal edema is important but not the immediate priority. While edema can be associated with preeclampsia, the presence of proteinuria and elevated blood pressure are more critical indicators that need to be addressed first.

Choice D rationale

Establishing the frequency of headaches is useful information but not the immediate priority. The combination of an excruciating headache and elevated blood pressure necessitates a more urgent assessment for preeclampsia, starting with a urine sample for protein.

A. Give zidovudine 6 to 12 hours after birth. B. Administer antibiotics for 7 to 10 days. C. Delay the initial bath for 1 to 2 days. D. Encourage breastfeeding every 2 to 3 hours.

Correct Answer is A

Explanation

Choice A rationale

Giving zidovudine 6 to 12 hours after birth is crucial as it helps prevent mother-to-child transmission of HIV. Early administration of antiretroviral medication reduces the risk of the newborn acquiring HIV significantly.

Choice B rationale

Administering antibiotics for 7 to 10 days is not standard practice for newborns of HIV-positive mothers unless there is an indication of infection. The primary intervention is antiretroviral therapy.

Choice C rationale

Delaying the initial bath for 1 to 2 days is not standard practice for preventing HIV transmission. It is important to bathe the newborn shortly after birth to remove any potential HIV-containing fluids.

Choice D rationale

Encouraging breastfeeding every 2 to 3 hours is not advised for HIV-positive mothers as HIV can be transmitted through breast milk. Alternatives such as formula feeding are recommended to prevent transmission. .

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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 A

Explanation

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