The emergency department nurse is assessing a 14-month-old child who was left inside a closed car for an hour. The outside temperature was 88 degrees Fahrenheit. Which assessment findings will the nurse report immediately to the health care provider? Select all that apply.

Choice A reason: A colouring book may not be the best choice for a 12-month-old as it requires fine motor skills that are still developing at this age. Additionally, crayons can pose a choking hazard.

Choice B reason: Large building blocks are appropriate for a 12-month-old toddler. They promote gross motor skills, hand-eye coordination, and cognitive development. These blocks are easy to grasp and safe for young children.

Choice C reason: Hanging crib toys are more suitable for younger infants who are not yet mobile. A 12-month-old is likely more interested in interactive and manipulative toys that they can hold and manipulate.

Choice D reason: Modelling clay is not recommended for a 12-month-old due to the potential choking hazard and the fact that the child may try to put it in their mouth.

Choice A reason: Obtaining an arterial blood gas is not typically a routine intervention immediately following a caesarean section. Arterial blood gas measurements are usually performed if there is a specific indication or concern about the baby's respiratory status or acid-base balance. Routine care focuses on stabilizing and assessing the baby rather than performing invasive procedures unless clinically indicated.

Choice B reason: Ensuring thermoregulation is a crucial intervention for newborns, especially those delivered by caesarean section. Maintaining an appropriate body temperature is essential to prevent hypothermia, which can lead to complications such as metabolic disturbances and respiratory issues. The nurse should use measures like pre-warmed blankets and radiant warmers to keep the baby warm and stable.

Choice C reason: Administering oxygen as needed is an important intervention to ensure the baby's oxygenation and respiratory stability. Newborns delivered by caesarean section may have transient respiratory difficulties due to the lack of the natural squeeze through the birth canal, which helps clear the lungs of fluid. Monitoring the baby's respiratory status and providing supplemental oxygen if necessary is vital for their well-being.

Choice D reason: Inserting an orogastric tube is not a standard routine intervention immediately after a caesarean section unless there is a specific indication, such as if the baby has difficulty feeding, significant respiratory distress, or gastrointestinal issues. Routine care focuses on more immediate stabilization measures unless clinical signs suggest the need for an orogastric tube.

Choice E reason: Keeping the head in a sniffing position is important for maintaining an open airway and ensuring effective ventilation. The sniffing position aligns the airway and promotes optimal breathing. This position is particularly useful for newborns who may have respiratory difficulties or require resuscitation efforts, ensuring that their airway remains patent and clear.