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?
Refer the child to social work for early intervention.
Educate the parents on the developmental delays their child is diagnosed with.
Provide the parents with pamphlets for support groups for children with developmental delays.
Discuss the assessment findings with the primary care provider.
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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Correct Answer is B
Explanation
Choice A rationale
Turning the child’s head to the side and pressing on the nasal ridge is not the recommended method for managing nosebleeds. This position can cause blood to flow into the throat, leading to swallowing blood and potential vomiting.
Choice B rationale
Sitting the child upright and leaning slightly forward while applying pressure to the sides of the nose is the correct method. This position helps prevent blood from flowing into the throat and allows it to clot more effectively.
Choice C rationale
Having the child lie flat and apply pressure to the cheeks is not effective for stopping a nosebleed. This position can cause blood to flow into the throat, leading to swallowing blood and potential vomiting.
Choice D rationale
Putting the child in bed, elevating the head slightly, and pressing on the forehead is not effective for stopping a nosebleed. The pressure needs to be applied directly to the soft part of the nose to control the bleeding.
Correct Answer is C
Explanation
Choice A rationale
Failure to thrive is a condition where a child does not gain weight or grow as expected. While severe diarrhea can contribute to failure to thrive, the immediate concern in this scenario is the significant weight loss indicating severe dehydration.
Choice B rationale
Malabsorption syndrome involves the inability to absorb nutrients properly, leading to malnutrition and weight loss. However, the acute weight loss in this case is more indicative of severe dehydration.
Choice C rationale
Severe dehydration is characterized by significant fluid loss, which can be life-threatening in infants. The weight loss from 11 pounds to 9 pounds, 8 ounces indicates a substantial fluid loss, pointing to severe dehydration.
Choice D rationale
Risk for fluid volume deficit is a potential diagnosis, but the significant weight loss and clinical presentation indicate that the infant is already experiencing severe dehydration.