An 18-month-old child returned from the cardiac cath lab 1/2 hour ago. The child wakes up and begins crying. The nurse notices that the pressure dressing is becoming saturated with blood. The nurse's first action should be to:

Remove the dressing to identify where the bleeding is coming from

Let the parent hold the child to calm him

Put direct pressure on the dressing to stop the bleeding

Draw up the ordered morphine to calm the child

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not a good choice. Removing the dressing to identify where the bleeding is coming from can increase the risk of infection and further bleeding. The nurse should keep the dressing in place and apply direct pressure to control the bleeding.

Choice B reason: This is not a good choice. Letting the parent hold the child to calm him can worsen the bleeding by increasing the blood pressure and heart rate. The nurse should keep the child in a supine position and reassure him while applying direct pressure to the dressing.

Choice C reason: This is the correct choice. Putting direct pressure on the dressing to stop the bleeding is the first and most effective action to take in this situation. The nurse should use a sterile gauze pad or a gloved hand to apply firm and continuous pressure to the dressing until the bleeding stops or medical assistance arrives.

Choice D reason: This is not a good choice. Drawing up the ordered morphine to calm the child is not the priority action in this situation. The nurse should first stop the bleeding and then assess the child's pain level and administer the appropriate analgesic. Morphine can also cause respiratory depression and hypotension, which can complicate the child's condition.

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Correct Answer is D

Explanation

Choice A reason: This statement is incorrect, as Tanner staging is not based on chronological age, but on the physical development of the child. Children may enter and progress through puberty at different ages, depending on their genetic, environmental, and nutritional factors.

Choice B reason: This statement is incorrect, as Tanner staging is not based on the sexual behavior of the child, but on the appearance of the external genitalia, breasts, and pubic hair. Sexual behavior is influenced by many factors, such as social, cultural, and psychological factors, and does not necessarily correlate with the stage of puberty.

Choice C reason: This statement is incorrect, as Tanner staging is not based on the increase in height and weight, but on the maturation of the reproductive organs and secondary sex characteristics. Height and weight are affected by many factors, such as nutrition, health, and genetics, and do not necessarily reflect the stage of puberty.

Choice D reason: This statement is correct, as Tanner staging is based on the predictable stages of puberty that are based on primary and secondary sexual characteristics. Primary sexual characteristics are the development of the internal and external reproductive organs, such as the ovaries, testes, uterus, penis, and vagina. Secondary sexual characteristics are the changes that occur in other parts of the body, such as the breasts, pubic hair, axillary hair, voice, and body shape.

A. Let the child hear the sounds of an ECG monitor. B. Avoid mentioning postoperative discomfort and interventions. C. Explain that an endotracheal tube will not be needed if the surgery goes well. D. Unfamiliar equipment should not be shown.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice. Letting the child hear the sounds of an ECG monitor can help reduce anxiety and fear of the unknown. It can also help the child understand what to expect during the surgery and recovery.

Choice B reason: This is not a good choice. Avoiding mentioning postoperative discomfort and interventions can create unrealistic expectations and mistrust. The nurse should provide honest and age-appropriate information about the surgery and the possible complications and pain management.

Choice C reason: This is not a good choice. Explaining that an endotracheal tube will not be needed if the surgery goes well can imply that the surgery might not go well and cause unnecessary worry. The nurse should explain that an endotracheal tube is a common device that helps the child breathe during and after the surgery and that it will be removed as soon as possible.

Choice D reason: This is not a good choice. Unfamiliar equipment should be shown and explained to the child and the family in a simple and reassuring way. This can help them become familiar with the equipment and reduce their fear and anxiety.

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An 18-month-old child returned from the cardiac cath lab 1/2 hour ago. The child wakes up and begins crying. The nurse notices that the pressure dressing is becoming saturated with blood. The nurse's first action should be to:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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