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A nursing student is caring for a child with trisomy 21 (Down syndrome) who has a fever and is experiencing difficulty breathing, Which intervention should the nurse prioritize?

Assess the child's respiratory status and oxygen saturation.

Provide comfort measures such as repositioning and soothing techniques.

Offer the child fluids to maintain hydration.

Administer a fever-reducing medication as ordered.

Answer and Explanation

The Correct Answer is A

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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Correct Answer is B

Explanation

A. Applying lidocaine/prilocaine cream 10 minutes prior would not be sufficient; it generally requires 30–60 minutes to be effective.

B. Flexing the chin to the chest and knees to the abdomen is the correct positioning for an infant during a lumbar puncture.

C. Keeping an infant NPO for 6 hours is unnecessary before a lumbar puncture.

D. Placing the infant in an infant seat post-procedure is not required; flat positioning is generally advised.

A. Stabilize the infant's spine. B. Palpate fontanel level. C. Assess pupillary reaction to light. D. Encourage the guardian to feed the infant. E. Measure the infant's head circumference. F. Evaluate for the presence of a Babinski reflex

Correct Answer is ["A","B","C","E"]

Explanation

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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A nursing student is caring for a child with trisomy 21 (Down syndrome) who has a fever and is experiencing difficulty breathing, Which intervention should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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