pediatric interventions

A toddler with hemophilia is hospitalized with multiple injuries after falling off a sliding board. X-rays reveal no bone fractures. When caring for the child, what is the nurse's highest priority?

Frequently assess LOC

The nurse is planning care with the parents of a 4-month-old infant with heart failure and congenital heart disease. The parents report that their child tires easily. Which of the following is a priority for this child?

Increase the number of rest periods

A nurse is assessing an 8-month-old infant during a wellness checkup. Which action is a normal developmental task for an infant this age?

Sitting without support

A 24-hour-old, full-term neonate is showing signs of possible sepsis. The nurse is assisting the primary health care provider with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure? Select all that apply.

1.Ensure a patent airway. 2.Hold the neonate steady in the correct position. 3.Maintain a sterile field.

A nurse is caring for a full-term neonate who is 24 hours old. Assessment findings include axillary temperature of 96.8° F (36° C), apical heart rate of 188 beats/minute, and respiratory rate of 48 breaths/minute. The mother reports that the neonate is lethargic when she tries to breast-feed and looks "like a rag doll." The mother also has a low-grade fever. Pulse oximetry reveals saturation of 89% on room air, and the neonate has dusky mucous membranes. What are the most appropriate nursing interventions? Select all that apply.

1.Provide blow-by oxygen and monitor the neonate's respiratory status. 2. Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. 3. Inform the parents that she wants to monitor the neonate closely.

When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of care. According to Erikson, offering choices helps the child achieve:

Autonomy

A 3-month-old has moderate dehydration. The nurse should assess the client for:

Oliguria