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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.

A.

Assess for changes in level of consciousness.

B.

Administer factor VIII.

C.

Perform passive range of motion hourly.

D.

Administer factor IX.

E.

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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Related Questions

Correct Answer is ["A","B"]

Explanation

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.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Cough

  • Hypertrophic Pyloric Stenosis: Pyloric stenosis typically causes forceful vomiting but does not cause coughing.
  • Gastroesophageal Reflux: Coughing can occur due to aspiration or irritation of the esophagus.

Recurrent Emesis

  • Hypertrophic Pyloric Stenosis: Projectile vomiting after feedings is a hallmark sign of pyloric stenosis.
  • Gastroesophageal Reflux: GER can also cause recurrent vomiting, though it is usually less forceful than in pyloric stenosis.

Inadequate Weight Gain

  • Hypertrophic Pyloric Stenosis: The inability to retain feedings can lead to poor weight gain.
  • Gastroesophageal Reflux: Reflux can also result in poor weight gain if feedings are frequently vomited.

Irritability

  • Hypertrophic Pyloric Stenosis: Hunger due to inadequate feeding can cause irritability.
  • Gastroesophageal Reflux: Discomfort from esophageal irritation can lead to irritability.

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