A nurse is bathing a toddler and notices the child has several bruises. Which of the following actions should the nurse take first?
Notify social services.
Ask the parents what caused the bruises.
Ask the toddler what caused the bruises.
Notify the provider.
The Correct Answer is B
A. Notify social services – Not the first action; the nurse must assess the situation before reporting.
B. Ask the parents what caused the bruises – Correct; gathering information helps differentiate normal bruising from possible abuse.
C. Ask the toddler what caused the bruises – Not the best initial approach, as toddlers may not provide reliable explanations.
D. Notify the provider – Appropriate but should come after assessing the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. At a non-palpable depth – Incorrect; the fundus is still palpable in the immediate postpartum period.
B. At the umbilicus – Correct; at 8 hours postpartum, the fundus is typically at the level of the umbilicus.
C. 2 cm below the umbilicus – Incorrect; the fundus begins to descend around 24 hours postpartum.
D. Just above the symphysis pubis – Incorrect; this occurs around day 10 postpartum.
Correct Answer is B
Explanation
A. Notify social services – Not the first action; the nurse must assess the situation before reporting.
B. Ask the parents what caused the bruises – Correct; gathering information helps differentiate normal bruising from possible abuse.
C. Ask the toddler what caused the bruises – Not the best initial approach, as toddlers may not provide reliable explanations.
D. Notify the provider – Appropriate but should come after assessing the situation.
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