The nurse is caring for a post-operative pyloromyotomy infant.
Which of the following interventions should be performed first?

Choice A rationale

Observing for signs of respiratory distress is the priority assessment for a child with burns to the face and neck. Burns in this area can lead to airway edema and compromise, which can rapidly become life-threatening. Assessing for stridor, hoarseness, difficulty breathing, and changes in respiratory rate and effort is crucial for immediate intervention.

Choice B rationale

Monitoring vital signs for indications of shock is important in burn patients due to fluid shifts and potential hypovolemia. However, airway patency takes precedence, as inadequate oxygenation will quickly lead to irreversible damage. Vital signs should be monitored continuously after ensuring the airway is secure.

Choice C rationale

Obtaining a detailed history of the burn incident is necessary for understanding the mechanism of injury and potential associated trauma. However, the immediate priority is to assess and manage any threats to the child's airway, breathing, and circulation. History taking can occur once the child is stable.

Choice D rationale

Evaluating the extent and depth of the burns is crucial for determining the severity of the injury and guiding fluid resuscitation and wound care. However, ensuring a patent airway and adequate breathing is the immediate priority upon the child's arrival in the emergency department.

Choice A rationale

Analgesics might mask pain, which is an important indicator of the child's condition and potential complications. While pain management is crucial, it is not the most immediate or specific intervention for hematuria in acute glomerulonephritis. The primary focus is on managing the kidney inflammation and its effects.

Choice B rationale

A high-protein diet is generally contraindicated in acute glomerulonephritis, especially when kidney function is compromised. Damaged glomeruli struggle to filter protein waste products, leading to increased urea and potential azotemia. Dietary protein is usually restricted during the acute phase to reduce the workload on the kidneys.

Choice C rationale

Monitoring urine output is essential in acute glomerulonephritis as it directly reflects kidney function. Reduced urine output (oliguria) or its cessation (anuria) can indicate worsening kidney failure. Close monitoring helps assess the severity of the condition and the effectiveness of treatment interventions aimed at preserving renal function. Normal urine output for children varies with age and weight but is generally around 1-2 mL/kg/hour.

Choice D rationale

While maintaining adequate hydration is important, encouraging excessive fluid intake in a child with acute glomerulonephritis and hematuria can lead to fluid overload. Impaired kidney function can result in the inability to excrete excess fluid, potentially causing hypertension, edema, and even heart failure. Fluid balance must be carefully managed.