A newborn is admitted with a diagnosis of a spiral fracture of the right femur. The mother states the child received the injury when the baby fell off the changing table. Which would be the priority nursing intervention?
Call the child abuse hotline
Educate the mother on safety
Inform the mother to call the nurse for all diaper changes
Complete the Morse Fall Scale
The Correct Answer is A
A. Call the child abuse hotline. A spiral fracture, especially in a non-ambulatory infant, is highly suspicious for non-accidental trauma (child abuse). Reporting suspected abuse is mandatory to protect the child from further harm.
B. Educate the mother on safety. While important for prevention, addressing potential abuse takes precedence.
C. Inform the mother to call the nurse for all diaper changes. This does not address the immediate concern of suspected child abuse.
D. Complete the Morse Fall Scale. This is irrelevant in the context of suspected child abuse.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","F"]
Explanation
A. Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.
Correct Answer is B
Explanation
A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.
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