A nurse is caring for an infant in the emergency departme

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A nurse is caring for an infant in the emergency department.

Exhibits

Which of the following actions should the nurse take? (Select all that apply.)

Evaluate for the presence of a Babinski reflex

Assess pupillary reaction to light.

Encourage the guardian to feed the infant

Palpate fontanel level

Stabilize the infant's spine.

Measure the infant's head circumference

Answer and Explanation

Correct Answer : B,D,E,F

A. While the Babinski reflex can be assessed in older children, it is not an appropriate reflex to assess in an 11-month-old infant. Infants typically show a different reflex pattern, and the Babinski reflex may not provide meaningful insight in this age group. The focus should be on vital neurological signs like pupil reaction and fontanel assessment.

B. The infant's pupils should be regularly monitored for changes, as a decrease in pupil reaction or size could indicate increased intracranial pressure (ICP), which may be related to the subdural hematoma. This is a critical assessment to identify neurological changes.

C. The infant’s difficulty waking could indicate a change in neurological status, potentially due to increased ICP or other complications from the subdural hematoma. Feeding should not be encouraged until the infant is fully alert and stable to avoid the risk of aspiration or choking. Instead, the infant's neurological status should be assessed further.

D. In infants, the fontanels are a key indicator of increased intracranial pressure. A bulging fontanel can indicate rising ICP, which requires immediate intervention. This should be checked regularly in cases of head trauma.

E. Since the infant has fallen from a height (a flight of stairs), spine stabilization is necessary until spinal injury can be ruled out. The infant should be moved cautiously, and spine precautions should be maintained to prevent further injury.

F. Monitoring the head circumference is essential for detecting any signs of increased ICP. A sudden increase in head circumference may suggest worsening edema or hemorrhage, especially in the setting of a subdural hematoma.

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Correct Answer is B

Explanation

A. Reminding the child to tell the nurse when they need to urinate is a helpful approach but may not be effective for managing urinary incontinence.

B. Taking the child to the bathroom every 2 hours helps manage incontinence by establishing a regular routine and preventing accidents.

C. An indwelling urinary catheter is not appropriate unless there is a medical need and is not used as a first-line intervention for behavioral incontinence.

D. Using diapers may provide short-term management, but it does not address the underlying behavior and could reinforce incontinence.

A. Irritability B. Yellow nasal discharge C. Facial edema D. Poor appetite

Correct Answer is C

Explanation

A. Irritability is common in nephrotic syndrome due to discomfort and illness but is not as urgent as severe edema.

B. Yellow nasal discharge is likely due to a concurrent cold and not a critical finding.

C. Facial edema can be a sign of worsening nephrotic syndrome and should be reported to the provider, as it can indicate fluid retention or complications.

D. Poor appetite is common in nephrotic syndrome but does not require immediate reporting unless there are other signs of deterioration.

View Question and Answer

A nurse is caring for an infant in the emergency department.

Exhibits

Which of the following actions should the nurse take? (Select all that apply.)

View Question and Answer

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A nurse is caring for an infant in the emergency department.

Exhibits

Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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Resources

A nurse is caring for an infant in the emergency department. Exhibits Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assessing a toddler who has acute nephrotic syndrome. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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A nurse is caring for an infant in the emergency department.

Exhibits

Which of the following actions should the nurse take? (Select all that apply.)