Difficulty: Medium
Average Score: 62%
Simulated
Passage / Scenario
11-month-old infant reportedly fell down a flight of stairs from the porch to the sidewalk. CT scan shows small subdural hematoma. Admit for close observation. Vital Signs Admission: Axillary temperature 37.1° C (98.8° F), Apical heart rate 104/min, Respiratory rate 26/min, Oxygen saturation 98% on room air. 4 hr later: Axillary temperature 38.2° C (100.8° F), Apical heart rate 124/min, Respiratory rate 22/min, Oxygen saturation 96% on room air. Nurses' Notes Admission note: Infant alert and fussy in guardian's arms. Moves all extremities. Edema and ecchymosis noted on left side of scalp. Anterior fontanel level and soft. Pupils equal and react briskly to light. 4 hr later: Infant sleeping in guardian's arms. Guardian reports they are unable to wake the infant to feed them. Infant slept through vital sign assessment.A nurse is caring for an infant in the emergency department. Which of the following actions should the nurse take?
Correct answer
A,B,C,E
Rationale
The correct actions for the nurse to take are stabilizing the infant's spine (A), palpating fontanel level (B), assessing pupillary reaction to light (C), and measuring the infant's head circumference (E). Stabilizing the spine is crucial in cases of trauma to prevent further injury. Palpating fontanel level helps assess for dehydration or intracranial pressure. Assessing pupillary reaction to light is a neurological assessment to check for any abnormalities. Measuring head circumference is important for monitoring growth and detecting any abnormalities. Encouraging feeding (D) and evaluating for Babinski reflex (F) are not immediate priorities in an emergency setting and can be addressed later.