A nurse in the emergency department is caring for a preschool-age child who has hemophilia A and sustained an abdominal trauma following a motor vehicle crash. Which of the following actions should the nurse take?

Select all that apply.

Assess for changes in level of consciousness.

Administer factor VIII.

Perform passive range of motion hourly.

Administer factor IX.

Apply a warming blanket over the child.

Answer and Explanation

Correct Answer : A,B

A. Assess for changes in level of consciousness. Abdominal trauma can lead to internal bleeding, which might increase intracranial pressure if bleeding occurs in the brain. Monitoring for neurological changes is essential.
B. Administer factor VIII. Hemophilia A results from factor VIII deficiency, and replacing it prevents further bleeding.
C. Perform passive range of motion hourly. Movement may exacerbate bleeding into the joints or injured tissues. Rest is essential during acute bleeding episodes.
D. Administer factor IX. Factor IX is used for hemophilia B, not hemophilia A.
E. Apply a warming blanket over the child. Hypothermia management may be necessary in some trauma cases, but there is no indication it is needed here based on the scenario provided.

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Correct Answer is C

Explanation

A. "The infant exhibits a fear of strangers." Stranger anxiety typically develops around 6 to 9 months of age.
B. "The infant understands the word 'no'." Understanding simple words like "no" begins closer to 9 months to 1 year of age.
C. "The infant has an absent grasp reflex." The grasp reflex begins to disappear by 3 months of age, with voluntary grasping developing by 4 to 5 months.
D. "The infant rolls from their back to their abdomen." Rolling from back to abdomen usually occurs around 5 to 6 months.

A. "Place your baby in a side-lying position when sleeping." B. "Use a drop-side crib until your baby is at least 6 months old." C. "Apply a plastic mattress cover to your baby's bed to protect it." D. “Keep your infant restrained when they are in a highchair."

Correct Answer is D

Explanation

A. "Place your baby in a side-lying position when sleeping." The recommended sleep position for infants is on their back to reduce the risk of sudden infant death syndrome (SIDS).
B. "Use a drop-side crib until your baby is at least 6 months old." Drop-side cribs are not recommended due to the risk of injury or suffocation; they have been banned in many regions.
C. "Apply a plastic mattress cover to your baby's bed to protect it." Plastic mattress covers increase the risk of suffocation and are not recommended.
D. "Keep your infant restrained when they are in a highchair." Proper restraints prevent falls or injuries when the infant is seated in a highchair.

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A nurse in the emergency department is caring for a preschool-age child who has hemophilia A and sustained an abdominal trauma following a motor vehicle crash. Which of the following actions should the nurse take? Select all that apply.

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A nurse in the emergency department is caring for a preschool-age child who has hemophilia A and sustained an abdominal trauma following a motor vehicle crash. Which of the following actions should the nurse take?

Select all that apply.