Difficulty: Medium
Average Score: 85%
Simulated
Passage / Scenario
An 8-month-old infant has a hypercyanotic spell while blood is being drawn.What is the priority nursing action?
Correct answer
B
Rationale
The correct answer is B: Place the child in the knee-chest position. This is the priority nursing action for a child with intussusception, a serious condition where a part of the intestine slides into an adjacent part. Placing the child in the knee-chest position helps relieve pressure and may assist in reducing the intussusception. Option A is incorrect as preparing the family for imminent death is not the priority at this time. Option C is incorrect as assessing for neurologic defects is not relevant to the immediate management of intussusception. Option D is incorrect as cardiopulmonary resuscitation is not indicated unless the child becomes unresponsive.