A nurse is preparing to administer a nasogastric (NG) tube feeding to a school-age child. Which of the following actions should the nurse plan to take?

Rationale:

• Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: The nurse should follow the ordered transfusion rate and not titrate it based on blood pressure. The priority is to transfuse the blood safely and at the prescribed rate, while monitoring the client's response. Blood pressure will improve as the blood volume is restored.
• Obtain the first unit of packed RBCs from the blood bank: This is necessary to correct the client’s anemia (Hgb 9.1 g/dL, Hct 27%) and address the suspected acute blood loss indicated by positive hemoccult stool and hemodynamic changes.
• Document the blood product transfusion in the client's medical record: Accurate documentation ensures legal compliance, tracks the administration, and records the client’s response, including any adverse events, supporting continuity of care.
• Stay with the client for the first 15 min of the transfusion: Most transfusion reactions occur during the first 15 minutes. Close observation allows for immediate intervention if the client develops fever, hypotension, or other adverse effects.

• Start an IV bolus of lactated Ringer's solution: Lactated Ringer’s contains calcium which can cause clotting in the transfusion line. Using LR can lead to hemolysis or transfusion complications. Only 0.9% sodium chloride should be used for flushing or running alongside blood transfusions.

A. Both fontanels are the same size: Fontanels differ in size and shape; the anterior is larger and diamond-shaped, while the posterior is smaller and triangular. Expecting them to be the same size is inaccurate.

B. The anterior fontanel is open: The anterior fontanel typically remains open until about 12–18 months of age. At 8 months, an open anterior fontanel is an expected finding and indicates normal skull development.

C. The posterior fontanel is open: The posterior fontanel usually closes by 6–8 weeks of age. An open posterior fontanel at 8 months may indicate delayed closure and should be evaluated further.

D. Both fontanels show molding: Molding refers to overlapping of cranial bones during birth. At 8 months, molding should no longer be present; its presence is not a normal finding at this age.