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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Protective isolation is not necessary for this client.
B. Log rolling every 4 hours maintains spinal alignment and prevents strain on the surgical area.
C. PCA pumps are often used for pain control after major surgeries like spinal instrumentation.
D. Keeping the head of the bed at a low angle (no more than 30°) helps reduce strain on the spine.
Correct Answer is A
Explanation
A. Assessing respiratory status and oxygen saturation is the priority to monitor for any respiratory distress.
B. Comfort measures can be provided but are secondary to assessing breathing difficulty.
C. Hydration is important but does not take precedence over respiratory assessment.
D. Administering a fever-reducing medication is supportive but does not address the breathing difficulty directly.
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