A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?
Ask a psychiatrist to talk with the parents.
Separate the child from the parents.
Report the suspected abuse to the authorities.
Obtain a detailed history.
The Correct Answer is D
a. While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
b. Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
c. Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however, obtaining a detailed history is the priority.
d. When a nurse observes several bruises on a child, the initial action should be to obtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Semi-Fowler's. While this position can help with drainage, it is generally not the first choice immediately after VP shunt surgery.
B. Prone.This position is generally not recommended as it can cause discomfort and increase intracranial pressure.
C. Trendelenburg. This position is contraindicated as it can significantly increase intracranial pressure.
D. on the unoperated side. This position helps prevent pressure on the operative site and facilitates drainage of cerebrospinal fluid. It also reduces the risk of complications associated with increased intracranial pressure.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Encouraging the infant to stand in the crib while in a cast for developmental dysplasia of the hip (DDH) supports gross motor development and maintains neuromuscular stimulation. Standing promotes proprioceptive input, strengthens postural muscles, and supports bone mineralization through weight-bearing. Infants in hip spica casts or orthotic devices can safely stand with supervision, preserving developmental milestones. Normal serum calcium ranges from 8.5 to 10.5 mg/dL, and mechanical loading enhances osteoblastic activity and skeletal growth.
Choice B rationale: While electronic toys offer sensory stimulation, they do not adequately support gross motor development in infants with DDH. At 10 months, infants require opportunities for vertical positioning and weight-bearing to stimulate vestibular and musculoskeletal systems. Passive play with electronic toys may delay motor milestones such as cruising and standing. Developmental progress depends on integrated sensory-motor experiences, and reliance on sedentary toys may limit engagement of core and lower limb musculature.
Choice C rationale: Latex balloons pose a significant safety hazard due to the risk of aspiration and suffocation. When burst, latex fragments can occlude the airway, especially in infants with underdeveloped protective reflexes. The tracheal diameter in infants averages 4 to 5 mm, making obstruction by balloon fragments potentially fatal. Additionally, latex exposure may trigger allergic reactions, particularly in atopic individuals. The American Academy of Pediatrics strongly advises against latex balloon use in children under 8 years.
Choice D rationale: Prompt diaper changes are essential for skin integrity, especially under a cast where moisture retention can lead to maceration and infection. However, this action does not directly promote growth and development. It is a hygiene measure that prevents irritant contact dermatitis and secondary infections such as Candida albicans. Normal skin pH ranges from 4.5 to 5.5, and prolonged exposure to urine and feces elevates pH, disrupting the acid mantle. While necessary, it lacks developmental stimulation.
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