Exhibits
A nurse is caring for a child who is 2 hr postoperative. Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Assess the child's pain level.
Recheck the child's temperature.
Determine the child's sedation level.
Compare the child's pedal pulses.
The Correct Answer is D
A. Assessing the child's pain level is important but may not be the first priority postoperatively, especially if there are signs of compromised circulation.
B. Rechecking the child's temperature is important but may not be the first priority postoperatively unless there are specific concerns related to temperature regulation.
C. Determining the child's sedation level is important for monitoring but may not be the first priority unless there are signs of respiratory compromise or other urgent concerns.
D. Comparing the child's pedal pulses is crucial in this situation as the child has undergone surgical procedures on the lower extremity, and changes in pedal pulses could indicate compromised circulation, which requires immediate attention to prevent complications such as compartment syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Newborn's eyes should be protected from direct phototherapy light, but they do not need to be checked every 8 hours specifically.
B. Monitoring the newborn's temperature is essential to ensure that the phototherapy is not causing overheating or hypothermia.
C. Placing mittens on the newborn’s hands may be unnecessary unless they are scratching or disrupting the phototherapy.
D. Applying lotion may interfere with the phototherapy and should be avoided, as it could create a barrier to the light therapy.
Correct Answer is D
Explanation
A. The Babinski reflex is normal in infants up to 12-18 months and does not require intervention.
B. The presence of tears when crying is a normal finding and does not indicate a concern.
C. The Doll's eye reflex (in which the eyes remain fixed when the head is turned) is normal in infants and does not require intervention.
D. At 4 months of age, infants should still have head lag when pulled to a sitting position. If there is no head lag, this may indicate a neurological issue or developmental delay.
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