Maternal Chap 52

The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern?

Inspection shows a sluggish pupillary reaction.

The nurse is providing support to the parents of a 10-year-old boy receiving emergency care. The boy is their foster child. Which comment will be most effective?

"Hold your child's hand while this is going on."

A 13-year-old adolescent has had a near-drowning experience. The nurse notices the client has labored breathing and a cough. What is the priority intervention?

Administer 100% oxygen by mask.

The nurse is preparing to administer oral acetylcysteine to a 9-year-old child with acetaminophen toxicity exhibiting nausea and abdominal tenderness. Which age-appropriate action should the nurse take when administering this medication?

Administer the medication in a small amount of a carbonated beverage.

An 8-year-old child is brought to the emergency department by paramedics who report the child has second-degree (partial-thickness) burns on the chest and legs. The child has also suffered smoke inhalation. What is the nursing priority in the care of this child?

Airway management

A child who suffered a blow to the abdomen while snowboarding comes to the emergency department with severe abdominal pain, especially on inspiration. The child is tachycardic, hypotensive, anxious, and very pale. The hematocrit is falling quickly. The health care provider indicates a liver rupture. What is the initial nursing action?

Begin an intravenous line

A 9-year-old girl who has fallen from a second-story window is brought to the emergency department. Which assessment would be the priority?

Monitoring oxygen saturation levels

The nurse is caring for an adolescent brought to the emergency department with an acetaminophen overdose. The nursing care begins with an assessment and intravenous catheter (IV) placement and includes the anticipated administration of which agent?

N-acetylcysteine

The nurse is caring for a 4-year-old client with head trauma. Which intervention should the nurse anticipate first?

Neck stabilization with brace

The nurse is caring for a 7-year-old child who exhibits symptoms of anaphylactic shock after being stung by a bee. The nurse notes that the child's lips are swelling. The nurse hears audible wheezing with dyspnea. Which intervention will the nurse perform first?

Place an endotracheal tube insertion tray at bedside.

A child admitted with extensive burns is now being allowed to eat. When assisting with the child's nutrition, the nurse would encourage intake of which nutrient?

Protein

When creating a care plan for a child with a head injury, the nurse uses the nursing diagnosis of Risk for excess fluid volume related to administration of hypertonic solution. Which is an appropriated outcome evaluation for this diagnosis?

The child's lungs remain clear to auscultation.

A nurse has received the above hand-off report from the emergency department. The nurse creates a plan of care for the child. What is the nurse's priority in providing care for the child?

Gas exchange

The nurse is caring for an adolescent who has suffered a first-degree partial thickness burn to their forearm. Which statement by the parent indicates a need for further education?

"If feeling better, going to a friend's house and swimming will be a good distraction."

A 13-year-old client suffered a serious fall while hiking with friends and suffered a head injury. Upon arrival to the emergency department, the nurse notices clear fluid from the nose. A friend said that the client had been sneezing a lot from a pollen allergy. Which intervention will the nurse implement to determine whether the fluid is cerebrospinal fluid (CSF) or mucus from allergic rhinitis (hay fever)?

Test the secretions with a glucose reagent strip.

A child who weighs 53 lbs (24 kg) is receiving fluid volume replacement as part of the treatment for shock. The nurse is evaluating the child's hourly urinary output to determine if the child's condition is improving. Which output would the nurse interpret as most indicative of improvement?

30 ml

The nurse is preparing to transfer a child from the busy emergency department to an inpatient pediatric unit. What action by the nurse is best?

Accompany the child and parents to the pediatric unit after calling verbal report to the unit and providing hand-off to the client's new nurse.

The nurse is assessing a child who has been injured. What assessment finding would support the need to initiate a notification to the abuse registry so that child protection specialists can investigate?

The child and parent have conflicting stories on what caused the injury.

A child has fallen from a swing at the playground and the parent states that the child became groggy. After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next?

Assess the level of consciousness.

A nurse is caring for a toddler in stable condition after being diagnosed with accidental poisoning due to the ingestion of cleaning solution. What teaching point is essential prior to discharge?

Keep cleaning solutions in a locked area.

The nurse is caring for a comatose school-age child receiving gastrostomy tube feedings. The nurse aspirates 15 ml of stomach contents prior to administering a feeding. What is the appropriate action by the nurse?

Replace the stomach contents and continue with the feedings as prescribed.

While assessing a child with a suspected skull fracture, the nurse notes clear fluid draining from the child's nose. What is the priority action by the nurse?

Test the fluid with a glucose reagent strip.

A 10-year-old child comes to the emergency department as a victim of abuse. The child's parent reports that the child was hit repeatedly with a baseball bat a few hours prior. The initial assessment indicates the child's blood pressure is 84/40 mm Hg. The nurse would further assess the child for what finding?

injuries resulting in ongoing blood loss