A nurse is caring for a child who is in a halo vest for cervical traction. Which of the following actions should the nurse take?
Show the child's parent how to release tension on the bars.
Remove the vest for the child to sleep at night.
Check the child's pupillary response.
Apply a cervical collar if the child reports neck pain.
The Correct Answer is C
A. Show the child's parent how to release tension on the bars: The tension on the halo vest is adjusted by the healthcare provider, not by the parent. The nurse should not instruct the parent to release tension, as improper adjustments can lead to complications.
B. Remove the vest for the child to sleep at night: The halo vest should remain in place at all times, including during sleep, to maintain proper cervical traction and stabilization. Removing it may interfere with the healing process and cause further injury.
C. Check the child's pupillary response: Monitoring the pupillary response is important in a child with cervical traction to assess for any neurological changes. It helps identify signs of increased intracranial pressure or other neurological complications.
D. Apply a cervical collar if the child reports neck pain: The halo vest itself is designed to stabilize the neck, and the application of a cervical collar without provider guidance could interfere with the proper use of the traction system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “I will push the medication to the back of my baby's mouth quickly using a syringe":
Pushing medication to the back of the mouth quickly could cause the baby to gag or choke. It’s better to administer the medication slowly to ensure the baby swallows it safely.
B. "I will gently squeeze my baby's cheeks when giving the medication.": Gently squeezing the baby's cheeks helps guide the baby to open their mouth and accept the medication. This ensures safe administration of oral medications without causing discomfort or distress.
C. "I will add the medication to 8 ounces of formula": Adding medication to formula is not recommended as it can alter the medication's effectiveness and make it harder to ensure the correct dosage. It is better to give the medication separately from formula.
D. "I will mix the medication in a 4-ounce bowl of rice cereal at breakfast": Mixing the medication with rice cereal could lead to the baby not receiving the full dose if they do not finish the cereal. Medications should generally be administered separately to ensure the full dose is given.
Correct Answer is "{\"xRanges\":[207.828125,247.828125],\"yRanges\":[145,185]}"
Explanation
Point A: Represents the third intercostal space at the right sternal border, which corresponds anatomically to the aortic valve area. This is a key auscultation site used during cardiac assessment to listen for murmurs and abnormalities related to the aortic valve. It is not used for palpation.
Point B: Fourth intercostal space at the left midclavicular line and is the correct location for palpating the point of maximal impulse (PMI) in infants and young children. In this age group, the PMI is typically found here due to the more horizontal position of the heart in the chest.
Point C: This location is at the 2nd or 3rd intercostal space, which is too high to assess the PMI in an infant. This area is used more for evaluating pulmonic valve sounds, not the apex of the heart.
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