A nurse is admitting a child who has acute epiglottitis. Which of the following actions should the nurse take?
Obtain a throat culture.
Initiate droplet isolation precautions.
Assist the child into a supine position.
Check oxygen saturation every 4 hr.
The Correct Answer is B
The nurse should initiate droplet isolation precautions when admitting a child who has acute epiglottitis.
Epiglottitis is commonly caused by Haemophilus influenzae type B and can be transmitted through respiratory droplets.
Choice A is wrong because obtaining a throat culture is not recommended when epiglottitis is suspected, as it can cause further obstruction of the airway.
Choice C is wrong because assisting the child into a supine position can worsen the airway obstruction.
Children with epiglottitis prefer to sit upright with the chin extended and mouth open.
Choice D is wrong because checking oxygen saturation every 4 hours may not be frequent enough for a child with acute epiglottitis who may require continuous monitoring of oxygen saturation.
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Related Questions
Correct Answer is D
Explanation
The correct answer is d. Exhibits head lag when pulled to a sitting position.
Choice A: Unable to hold a bottle At around 6 months of age, some babies can hold their own bottle. This is not a concerning finding for a 5-month-old infant. Therefore, this is not the correct answer.
Choice B: Unable to roll from back to abdomen Rolling over often starts around 4-6 months, so it’s not unusual for a 5-month-old to still be developing this skill. Therefore, this is not the correct answer.
Choice C: Absent grasp reflex The grasp reflex is an involuntary movement that your baby starts making in utero and continues doing until around 6 months of age. The grasp reflex lasts until the baby is about 5 to 6 months old. Therefore, this is not the correct answer.
Choice D: Exhibits head lag when pulled to a sitting position By the age of 5 months, most infants have developed enough strength in their neck and upper body to control their head movement. This means they should not exhibit a significant head lag when pulled to a sitting position1. If this is not the case, it could indicate a delay in motor development or a potential neurological issue, which should be reported to the healthcare provider for further evaluation. Therefore, this is the correct answer.
Correct Answer is D
Explanation
After a tonsillectomy surgery, it is important to place the child in a side-lying position to help keep their airway open and prevent aspiration 1.
Choice A is wrong because deep breathing and coughing may cause discomfort and bleeding after a tonsillectomy.
Choice B is wrong because while ice cream may be soothing for the throat, it is not the only food that can be offered when the child is alert.
Choice C is wrong because drinking fluids through a straw may cause discomfort and bleeding after a tonsillectomy.
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