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.)

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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Corticosteroid injections are used in severe cases but are not routine for mobility or pain relief in long-term management.

B. Hot compresses can provide temporary pain relief but do not address long-term mobility.

C. Regular physical activity and exercise are essential to maintain joint mobility, muscle strength, and reduce stiffness in juvenile idiopathic arthritis.

D. Limiting movement could lead to joint stiffness and decreased mobility, worsening the condition.

A. Encourage the child to bear weight on the affected limb B. Remove the traction periodically to allow the child to take a break C. Encourage the child to move the affected limb frequently D. Encourage the child to participate in physical activities to promote mobility E. Assess the child's neurovascular status regularly F. Monitor for signs of infection at the traction site G. Administer pain medication as needed H. Apply ice packs to the traction site to reduce swelling

Correct Answer is ["E","F","G"]

Explanation

A. Bearing weight on the affected limb is contraindicated in skeletal traction.

B. Traction should not be removed unless directed by the provider, as it could compromise the treatment.

C. Movement of the affected limb is generally restricted to prevent disrupting alignment.

D. Physical activity should be limited to prevent stress on the traction apparatus.

E. Regular neurovascular assessments help identify complications like compartment syndrome.

F. Monitoring for infection is essential due to the invasive nature of skeletal traction.

G. Pain management is important for patient comfort.

H. Ice is generally not applied directly to traction sites; instead, the nurse monitors for complications.

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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

When planning the discharge of a child with juvenile idiopathic arthritis, which intervention should the nurse include in the plan of care to promote joint mobility and reduce pain?

Correct Answer is C

Explanation

Which of the following actions should the nurse take when caring for a child in skeletal traction? (Select All that Apply)

Correct Answer is ["E","F","G"]

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.)