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A nurse is assessing a 3-year-old child and suspects the child may have a developmental delay. Which of the following actions is a priority for the nurse to take?

A.

Refer the child to social work for early intervention.

B.

Educate the parents on the developmental delays their child is diagnosed with.

C.

Provide the parents with pamphlets for support groups for children with developmental delays.

D.

Discuss the assessment findings with the primary care provider.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Referring the child to social work for early intervention is important, but it is not the immediate priority. The nurse should first discuss the assessment findings with the primary care provider to confirm the diagnosis and plan the next steps.

 

Choice B rationale

 

Educating the parents on the developmental delays their child is diagnosed with is essential, but it should come after a confirmed diagnosis and a comprehensive plan is in place. The primary care provider should be involved in this process.

 

Choice C rationale

 

Providing the parents with pamphlets for support groups is supportive but not the immediate priority. The nurse should first ensure that the primary care provider is aware of the assessment findings to confirm the diagnosis and plan appropriate interventions.

 

Choice D rationale

 

Discussing the assessment findings with the primary care provider is the priority action. This ensures that the child receives a thorough evaluation and appropriate interventions are planned based on a confirmed diagnosis.


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Placing the child in a knee-chest position helps increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation during a cyanotic spell in children with Tetralogy of Fallot.

Choice B rationale

Having the child lie supine with the head turned to one side does not help in managing a cyanotic spell and may not improve oxygenation.

Choice C rationale

Lying prone does not specifically address the cyanotic spell and may not be the most effective position for improving oxygenation.

Choice D rationale

Placing the child in a semi-Fowler’s position in an infant seat does not specifically address the cyanotic spell and may not be the most effective position for improving oxygenation.

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

Restraining the client during a seizure is not recommended as it can cause injury. The focus should be on ensuring the client’s safety and preventing harm.

Choice B rationale

Assessing the client’s airway patency is crucial during a seizure to ensure that the client is breathing properly and that the airway is not obstructed.

Choice C rationale

Removing objects from the client’s bed helps prevent injury during a seizure. Objects in the bed can pose a risk of harm if the client hits them during the seizure.

Choice D rationale

Placing the client in a side-lying position helps maintain an open airway and reduces the risk of aspiration. This position allows any secretions to drain out of the mouth, preventing choking.

Choice E rationale

Placing a tongue depressor in the client’s mouth is not recommended and can cause injury. It is a common misconception that this prevents the client from swallowing their tongue, but it can actually cause more harm.

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