The nurse is sitting at the desk watching the telemetry monitors and notes a patient's rhythm suddenly shows asystole. Which action should the nurse take first?

A. A 14-month-old toddler with bruises on bony prominences:

Bruises on bony prominences are common in toddlers who are learning to walk and are prone to falls. While bruising can raise concerns, it is not necessarily indicative of physical abuse, especially in this age group.

B. A 9-month-old infant who sustained near drowning:

Near drowning in an infant who climbed into the tub and turned on the water suggests an accidental event rather than physical abuse. This scenario is consistent with lack of supervision or an unfortunate accident.

C. A 3-year-old toddler with scalding burns:

Scalding burns from spilling hot tea on oneself can occur accidentally, especially in young children who may not understand the dangers associated with hot liquids. While the circumstances may raise suspicion, it does not necessarily indicate physical abuse without further evidence.

D. A 6-year-old child with a spiral fracture:

A spiral fracture of the tibia and fibula is concerning for physical abuse, especially in a child who reportedly sustained the injury while riding a bicycle. Spiral fractures are often associated with twisting or pulling forces and are considered suspicious for non-accidental trauma, particularly when there is no plausible explanation for the injury.

(a) Administer another dose of the beta-blocker as prescribed by the physician: Administering another dose of the beta-blocker may not be the best course of action. If the client is experiencing fatigue and weakness, it could be a sign that the medication’s side effects are causing these symptoms. Administering an additional dose may exacerbate these side effects. Adjusting the medication regimen should be done under the direction of the healthcare provider.

(b) Offer the client a salty snack to improve blood pressure: Offering a salty snack may increase blood pressure, but it does not address the underlying issue of the medication’s side effects. Moreover, a diet high in salt can lead to other health problems, such as heart disease and stroke.

(c) Document the client’s symptoms and notify the healthcare provider: Documenting the client’s symptoms and notifying the healthcare provider is the most appropriate initial nursing action. The healthcare provider needs to be informed so that appropriate changes to the medication regimen can be made.

(d) Encourage the client to participate in physical therapy exercises: While physical therapy exercises can be beneficial for overall health, they do not address the immediate concern of the medication’s side effects. The client’s symptoms are indicative of medication side effects rather than a lack of physical activity. While physical therapy is important, it is not the most immediate priority in addressing the client’s current symptoms.