In the pediatric emergency department, the nurse must prioritize patient care. Which patient should the nurse assess first?
The 1-month-old infant who has developed colic and is crying.
The 14-year-old adolescent whose mother suspects her child is sexually active.
The 2-year-old toddler who was bitten by another child at the day-care center.
The 6-year-old school-aged child who was hit by a car while riding a bicycle.
The Correct Answer is D
Choice A reason: While colic can be distressing, it is not life-threatening and does not require immediate assessment over more critical conditions.
Choice B reason: Suspicions of sexual activity in an adolescent are a concern but do not constitute an emergency that requires immediate assessment.
Choice C reason: A bite from another child, although potentially serious, is less urgent than a trauma case and can be assessed after more critical patients.
Choice D reason: This is the correct choice. A child hit by a car may have life-threatening injuries and requires immediate assessment and intervention.
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Correct Answer is C
Explanation
Choice A reason: Taking the child on a tour might be overwhelming and increase anxiety due to the new environment and sensory overload.
Choice B reason: Placing the child in a four-bed room could lead to overstimulation and discomfort due to the presence of multiple unfamiliar people.
Choice C reason: Orienting the child to the hospital room provides a safe and controlled environment, allowing for gradual adjustment to the new setting.
Choice D reason: Immediately taking the child to the playroom for arts and crafts might be too stimulating and could exacerbate stress rather than ease the transition.
Correct Answer is D
Explanation
Choice A reason:By around 12 months, infants typically triple their birth weight, but that milestone isn't expected at 6 months. Therefore, telling the mother three times birth weight at this age would be inaccurate and misleading.
Choice B reason: While it's true that each child grows at their own pace, there are general milestones for weight gain that can guide expectations.
Choice C reason: This choice is incorrect. A 10 lb increase is not a standard milestone for weight gain at 6 months.
Choice D reason: Evidence-based pediatric growth milestones state that by 6 months, an infant’s weight typically doubles from birth weight. This aligns with widely accepted developmental guidelines and is the most accurate and reassuring response to the mother’s question.
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