The nurse has reviewed the Provider Prescriptions.

Exhibits

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Rationale:

A. Establish a patent airway: Severe head trauma with active nasal bleeding raises concern for airway obstruction from blood pooling, impaired consciousness, or loss of protective reflexes. Ensuring a patent airway prevents hypoxia, which can rapidly worsen neurologic injury. Early airway control is the priority because compromised breathing poses an immediate threat to life

B. Prepare for a CT scan: A CT scan is essential for diagnosing intracranial injuries, fractures, and sources of bleeding, but the client must first have a stable airway and adequate oxygenation. Imaging cannot safely proceed until airway patency is confirmed, since deterioration during transport is a major risk.

C. Insert a peripheral IV line: IV access is necessary for fluid resuscitation and medication administration, but it is not the most urgent action when airway compromise is suspected. The risk of hypoxia outweighs the risk of delayed IV access, and airway management must occur before secondary stabilization steps. Once the airway is secured, IV access can be safely done.

D. Apply direct pressure to the nose: Direct pressure is generally used to control epistaxis, but in severe head trauma, nasal bleeding may indicate a basilar skull fracture, and pressure could worsen underlying injury or dislodge clots. Additionally, controlling bleeding is secondary to securing the airway, as blood flow can interfere with breathing.

Rationale:

• Measure the infant's weight daily: Daily weight monitoring is standard for postoperative infants to assess hydration status and overall recovery. Accurate weight helps guide fluid replacement and nutrition management.

• Initiate short breastfeeding sessions 12 hr postoperatively: Postoperative feedings usually begin relatively quickly (often 4-6 hours post-op) with small amounts of clear fluids or breast milk/formula, gradually increasing. 12 hours is an expected time frame to begin re-feeding/breastfeeding sessions.

• Place the infant in prone position after feeding: Infants are placed on their backs (supine) to reduce the risk of sudden infant death syndrome (SIDS). Prone positioning after feeding is not recommended in postoperative care unless specifically ordered for surgical reasons.

• Fold the infant's diaper below the incision site: Keeping the diaper below the surgical site prevents irritation, friction, or pressure on the incision, promoting healing and preventing infection. This is a standard nursing intervention after abdominal surgery in infants.