Exhibits

Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.

A. "Tell me what an operation is." This open-ended question allows the nurse to assess the child’s understanding of the procedure and address any misconceptions or fears. School-age children are in the concrete operational stage of cognitive development, meaning they benefit from clear, age-appropriate explanations. Encouraging them to express their thoughts helps the nurse provide reassurance and correct any misunderstandings.
B. "We're going to do everything we can to take very good care of you." While this statement is comforting, it does not encourage the child to share their knowledge or feelings about the surgery. Understanding the child’s perspective first allows for more effective education and emotional support.
C. "I'm glad your mother told you why you were coming to the hospital." While acknowledging parental involvement is positive, this response does not directly engage the child in conversation or assess their level of understanding. The nurse should focus on what the child knows and feels about the procedure.
D. "Are you scared?" Directly asking if the child is scared may lead to a yes-or-no answer and might introduce fear where it did not previously exist. Instead, allowing the child to explain their understanding of the operation provides insight into their concerns and gives the nurse an opportunity to offer appropriate reassurance.

A. Give blow-by oxygen via cannula. Blow-by oxygen is used for neonates who are breathing spontaneously but need supplemental oxygen. Since this newborn remains apneic despite stimulation, oxygen alone will not be sufficient to establish effective respiration.
B. Start IV infusion in a scalp vein. IV access may be needed later for medications or fluids, but the immediate priority is establishing effective breathing. Without adequate ventilation, oxygen delivery to tissues will be compromised, making IV interventions secondary.
C. Assist neonatologist with intubation. Intubation is reserved for neonates who fail to respond to positive pressure ventilation (PPV) or who require prolonged respiratory support. Since this newborn has a heart rate of 100 bpm and is apneic, PPV should be initiated first to stimulate breathing before considering intubation.
D. Provide positive pressure ventilation. PPV is the priority intervention for a newborn who remains apneic despite initial stimulation. A heart rate of 100 bpm is reassuring, but without spontaneous breathing, PPV is necessary to ensure adequate oxygenation and prevent further deterioration. Neonatal resuscitation guidelines recommend starting PPV within the first minute of life if the infant does not establish effective respirations.