A nurse is caring for an infant in the emergency department.
Stabilize the infant's spine.
Palpate fontanel level.
Assess pupillary reaction to light.
Encourage the guardian to feed the infant.
Measure the infant's head circumference.
Evaluate for the presence of a Babinski reflex
Correct Answer : A,B,C,E
A. This is crucial due to the potential for a spinal injury given the mechanism of the fall. Stabilizing the spine can help prevent further injury while the infant is being assessed.
B. Monitoring the fontanel is important to assess for increased intracranial pressure. The anterior fontanel should be flat and level; bulging could indicate swelling or pressure.
C. This is vital for evaluating neurological status and determining if there are any signs of increased intracranial pressure or brain injury.
D. This is not appropriate at this time, as the infant is difficult to awaken, which could indicate a risk for aspiration.
E. Measuring head circumference can help track changes and monitor for signs of increased intracranial pressure or other complications.
F. While assessing reflexes may provide information on neurological function, it is not the priority compared to the other actions listed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F"]
Explanation
A. Development of skin tags is a common manifestation due to hormonal changes associated with acromegaly.
B. A softening voice can occur due to enlargement of the vocal cords and surrounding tissues.
C. Weakness in voluntary muscles may result from hormonal effects on muscle tissue over time.
D. Involution typically refers to the reduction in size or activity of an organ or tissue, which is not characteristic of acromegaly.
E. Altered vital signs may occur, but are not specific or unique clinical manifestations of acromegaly.
F. Soft tissue swelling is a prominent feature due to excess growth hormone leading to tissue enlargement.
Correct Answer is B
Explanation
A. Blood pressure may fluctuate but is less sensitive as an early indicator of fluid resuscitation efficacy.
B. A decrease in heart rate is a sign of improved hydration status, as tachycardia is often a compensatory response to hypovolemia.
C. Weight is not used as an immediate indicator for fluid resuscitation adequacy.
D. Urine output should increase with adequate fluid resuscitation; a decrease in urine output would indicate worsening.
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