A nurse in an urgent care clinic is caring for a school-age child who has injuries resulting from physical maltreatment. Which of the following actions should the nurse take first?
Ensure the child's safety.
Tell the child they are not at fault.
Document the location of the child’s injuries
Notify local law enforcement.
The Correct Answer is A
Choice A reason:
Ensuring the child's safety is the top priority. If the child is in immediate danger, steps must be taken to protect them.
Choice B reason:
While providing emotional support to the child is important, ensuring their physical safety takes precedence.
Choice C reason:
Documenting injuries is important for a comprehensive assessment and for legal purposes, but it should follow ensuring the child's immediate safety.
Choice D reason:
Notifying law enforcement may be necessary, but ensuring the child's immediate safety comes first.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Placing a folded blanket to pad the back of the infant's head is not recommended, as it can interfere with the proper fit of the car seat harness and potentially be a safety hazard.
Choice B reason:
This statement is correct. Infant car seats should be positioned at a 30-degree angle to provide optimal support for the infant's head and neck, as well as to prevent airway obstruction.
Choice C reason:
While car seats with a four-point harness do exist, a standard infant car seat typically has a five- point harness system.
Choice D reason:
The retainer clip should be positioned at the level of the infant's armpits to ensure that the harness is snug and secure.
Correct Answer is B
Explanation
Choice A reason:
Administering digoxin should be based on the infant's specific heart rate and the healthcare provider's prescription, rather than a specific pulse value.
Choice B reason:
Allowing for frequent rest periods is important for an infant with heart failure, as it helps conserve energy and reduce cardiac workload.
Choice C reason:
Feeding duration should be based on the infant's tolerance and ability to feed effectively, rather than a specific time frame.
Choice D reason:
Maintaining the infant in a supine position can help with respiratory function but should be balanced with appropriate positioning to prevent aspiration and promote comfort. It is not the sole action to include in the plan of care.
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