A clinic nurse is assessing infants and toddlers for fine and gross motor development. Which child should the nurse refer to a healthcare provider for further evaluation?

Correct answer: D

D. Risk for infection related to impaired skin integrity: Bladder exstrophy exposes the bladder to the external environment, significantly increasing the risk of infection. This is a critical concern that requires immediate attention to prevent serious complications.

Incorrect:

A. Knowledge deficit related to caring for the infant: While educating the parents about caring for an infant with bladder exstrophy is important, it is not the highest priority compared to preventing infection.

B. Risk for impaired parenting related to appearance of the infant: While the appearance of the infant may be challenging for parents, addressing the immediate risk of infection is more critical.

C. Altered urinary elimination related to exposure of the bladder: This is a known consequence of bladder exstrophy and is addressed through surgical intervention and ongoing care. However, preventing infection is the most immediate priority.

A. Closing the blinds room so is darkened is inappropriate. The lighting in the room is unlikely to have an impact on the seizure or its management. Ensuring safety and maintaining the airway is the priority.

B.Asking the mother to release the child is appropriate. It’s important to ensure the safety of both the child and the mother. The mother should be asked to release the child to prevent any potential harm to the child during the seizure

C. Monitoring the child's airway and tongue is appropriate. During a seizure, there is a risk of the child's airway being compromised. The nurse should closely monitor the child's airway to ensure that it remains open and that the tongue does not obstruct the airway. Positioning the child on their side can also help prevent choking.

D. Administering an anticonvulsant medication is inappropriate. The nurse should not administer medication without a healthcare provider's order. In a seizure emergency, the focus is on maintaining safety and managing the seizure itself.

E. Place pillows inside the side rails: This is a correct action to prevent injury during the seizure. Padding the side rails helps protect the child from hitting their head or limbs on the hard surfaces.