A nurse is assessing a 2-year-old male toddler in a pediatric clinic during a well-child checkup.

Exhibits

After reviewing the toddler’s current medical record, which of the following interventions should the nurse expect the provider to prescribe?

Choice A rationale: Documentation of admission data should occur as soon as possible after the information is obtained. Waiting until the end of the shift to chart a summary increases the risk of forgetting critical details and delays the communication of important findings to the rest of the healthcare team.

Choice B rationale: The Patient Self-Determination Act requires healthcare facilities to ask clients upon admission if they have advance directives, such as a living will or a durable power of attorney for healthcare. This information must be clearly documented in the medical record to ensure the client's end-of-life wishes are respected.

Choice C rationale: The nursing process begins with assessment, not evaluation. Evaluation is the final step where the nurse determines if goals were met. Charting should follow the chronological order of the nursing process: assessment, diagnosis, planning, implementation, and finally, evaluation.

Choice D rationale: Registered nurses are responsible for the initial admission assessment, which includes the first set of vital signs. While assistive personnel can take routine vitals later, the nurse should personally obtain and document the baseline admission data to ensure accuracy and clinical oversight.

Choice A rationale

A child with a Wilms' tumor and an abdominal mass requires urgent attention and management. However, this is not an immediate life-threatening emergency. The primary concern is to avoid palpating the abdomen to prevent rupture of the encapsulated tumor, which could disseminate cancer cells. This is a critical care consideration but does not represent an immediate threat to the child's airway or circulation, which would be prioritized in triage.

Choice B rationale

A child with a urinary tract infection and bright red blood in their urine, or hematuria, requires a thorough assessment and medical intervention. Hematuria can indicate a significant underlying problem, but it does not represent an immediate threat to the child's airway, breathing, or circulation. The child's condition is stable compared to a child with an impending airway obstruction. This client would be assessed after more critical clients.

Choice C rationale

A child with mononucleosis reports severe fatigue, which is a common and expected symptom of the illness. The primary concern with mononucleosis is often splenic rupture, especially if the child is engaging in strenuous activity. However, fatigue itself is not an immediate life-threatening condition. This child would be assessed after more critical clients, as their airway and breathing are not compromised.

Choice D rationale

A child with acute epiglottitis who is drooling is the highest priority for assessment. This finding, combined with the diagnosis, is a classic sign of an impending airway obstruction due to the inflamed epiglottis. The child is unable to swallow their own saliva, indicating significant swelling. This is a medical emergency that can rapidly progress to complete airway occlusion and respiratory arrest, requiring immediate intervention to secure the airway. *.