A nurse is caring for a 10-month-old child who was brought to the emergency department by his parents following a head injury.
Which of the following actions should the nurse take first?
Assess respiratory status.
Inspect for fluid leaking from the ears.
Examine the scalp for lacerations.
Check pupil reactions.
The Correct Answer is A
The first action the nurse should take is to assess the respiratory status of the infant.
After a head injury, it is important to ensure that the child’s airway is clear and that they are breathing adequately.
This is a crucial step in providing care for a patient with a head injury.
Choice B is wrong because inspecting for fluid leaking from the ears is not the first priority.
Choice C is wrong because examining the scalp for lacerations is not the first priority.
Choice D is wrong because checking pupil reactions is not the first priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
According to the normal pediatric vital signs chart provided by Cleveland Clinic, the normal blood pressure range for a 2-year-old child should be between 90- 105/55-70 mm Hg. The blood pressure of 118/74 mm Hg is higher than the normal range for a 2- year-old child and should be reported to the provider.
Choice B is wrong because a respiratory rate of 26/min falls within the normal range of 20-30 breaths per minute for a child between ages 1 and.
Choice C is wrong because a pulse rate of 98/min falls within the normal range of 80-125 beats per minute for a child between ages 1 and.
Choice D is wrong because a temperature of 37.2° C (99° F) falls within the normal range for children which is around 98.6 degrees.
Correct Answer is C
Explanation
Bruises in areas of the body not typically injured by accident or normal childhood activities can be a potential indicator of physical abuse.
Choice A is wrong because Weight in 45th percentile is not an answer because it falls within the normal range for weight.
Choice B is wrong because Abrasions on the knees are not an answer because they are a common injury in children and can occur during normal play.
Choice D is wrong because Front deciduous teeth missing is not an answer because it is normal for children to lose their deciduous teeth.
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