A nurse is bathing a toddler and notices that she has several bruises.
Which of the following actions should the nurse take first?
Ask the parents what caused the bruises.
Ask the toddler what caused the bruises.
Notify social services.
Notify the provider.
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: The initial step in assessing unexplained bruising in a toddler is to gather information directly from the caregivers. This establishes a clinical baseline and allows the nurse to evaluate consistency, plausibility, and emotional responses. Bruising in toddlers can be developmental due to increased mobility, but patterns, location, and frequency matter. Normal platelet count ranges from 150,000 to 450,000/mm³; abnormal bruising may suggest thrombocytopenia, coagulopathy, or trauma. Early dialogue supports accurate documentation and escalation if needed.
Choice B rationale: While engaging the toddler may seem appropriate, their developmental stage limits reliable verbal communication. Toddlers typically lack the cognitive and linguistic capacity to describe events accurately, especially those involving trauma or abuse. Their responses may be influenced by fear, confusion, or limited vocabulary. Relying on their account prematurely risks misinterpretation and emotional distress. Assessment should prioritize adult sources first, followed by observational and clinical data to guide further action.
Choice C rationale: Notifying social services is a critical step in suspected abuse but must follow preliminary assessment and documentation. Premature reporting without context may lead to unnecessary distress for the family and compromise the integrity of the investigation. The nurse must first gather objective findings, caregiver explanations, and clinical indicators. Social services involvement is warranted when findings suggest non-accidental trauma, inconsistent histories, or high-risk environments. The decision must be evidence-informed and procedurally sound.
Choice D rationale: Notifying the provider is essential for collaborative care but should follow initial data collection. The provider relies on the nurse’s observations and caregiver input to determine next steps, including diagnostic testing or referral. Immediate escalation without context may delay appropriate triage or misdirect resources. The nurse’s role includes thorough documentation, pattern recognition, and initiating dialogue with caregivers to inform the provider’s clinical judgment. This ensures a coordinated, evidence-based response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Encouraging the infant to stand in the crib while in a cast for developmental dysplasia of the hip (DDH) supports gross motor development and maintains neuromuscular stimulation. Standing promotes proprioceptive input, strengthens postural muscles, and supports bone mineralization through weight-bearing. Infants in hip spica casts or orthotic devices can safely stand with supervision, preserving developmental milestones. Normal serum calcium ranges from 8.5 to 10.5 mg/dL, and mechanical loading enhances osteoblastic activity and skeletal growth.
Choice B rationale: While electronic toys offer sensory stimulation, they do not adequately support gross motor development in infants with DDH. At 10 months, infants require opportunities for vertical positioning and weight-bearing to stimulate vestibular and musculoskeletal systems. Passive play with electronic toys may delay motor milestones such as cruising and standing. Developmental progress depends on integrated sensory-motor experiences, and reliance on sedentary toys may limit engagement of core and lower limb musculature.
Choice C rationale: Latex balloons pose a significant safety hazard due to the risk of aspiration and suffocation. When burst, latex fragments can occlude the airway, especially in infants with underdeveloped protective reflexes. The tracheal diameter in infants averages 4 to 5 mm, making obstruction by balloon fragments potentially fatal. Additionally, latex exposure may trigger allergic reactions, particularly in atopic individuals. The American Academy of Pediatrics strongly advises against latex balloon use in children under 8 years.
Choice D rationale: Prompt diaper changes are essential for skin integrity, especially under a cast where moisture retention can lead to maceration and infection. However, this action does not directly promote growth and development. It is a hygiene measure that prevents irritant contact dermatitis and secondary infections such as Candida albicans. Normal skin pH ranges from 4.5 to 5.5, and prolonged exposure to urine and feces elevates pH, disrupting the acid mantle. While necessary, it lacks developmental stimulation.
Correct Answer is B
Explanation
This is an important measure to prevent the spreading of impetigo to others and to other parts of the body, as the bacteria can survive on clothing and other objects12.
Choice A.
Keeping the child on droplet precautions at home is incorrect, as impetigo is not spread by respiratory droplets, but by direct contact with the sores or contaminated items.
Choice C.
Immunizing household contacts for the disease is incorrect, as there is no vaccine for impetigo, which is caused by different types of bacteria.
Choice D.
Giving the child a chlorine bath twice daily is incorrect, as chlorine can irritate the skin and worsen impetigo.
The recommended treatment is to wash the sores with soap and water and
apply antibiotic ointment or cream23.
Therefore, choice B is the best answer to this question.
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