Child Health and Safety Guidelines, Exams of Pediatrics

Download Child Health and Safety Guidelines and more Exams Pediatrics in PDF only on Docsity! Pediatrics F INAL EXAM 135 Questions and Answers for 2024. The Emergency room nurse is concerned about what findings when a 5 month old infant is assessed? A. Anterior Fontanel is closed B. Child rolls from side to side C. Child is able to lift head D. Rooting reflex has disapeared - Correct answer A. Anterior Fontanel is Closed The parents of a 3 month old are instructed to have all family members and caregivers to have there tdap and dtap booster vaccines to prevent the potentially fatal illness? A. Rubella B. Mumps C. Measles D. Pertussis - Correct answer D. Pertussis A first time mother wants to start her 6 month old on solid foods . The nurse would educate the parent that she should begin with what food choices? A. any food the family is eating B. Strained meats C. Rice cereal mixed with whole cows milk D. Rice cereal for infants mixed with formula - Correct answer D. Rice cereal for infants mixed with formula A 7 month child that was full term is in a clinic for a well child visit . A early intervention consult would be indicated for which of the following findings? Select all that apply A. Pincer grasp B. Head lag C. Does not roll over D. Stranger anxiety - Correct answer B. Head lag C. Does not roll over A 9 month old is in for there well child visit the child has met all milestones. The nurse will provide additional health and safety information and educates her on foods to avoid until 1 yr of age. What would she include? Select all that apply A. Strained Banana B. Honey C. Peanuts D. Strained Carrots - Correct answer B. Honey C. Peanuts The mother of a 2 year old is concerned that her child is a picky eater .He is gaining weight and is in the 75th percentile on the growth chart ? The nurse would respond with the following statement A. This is normal development for a 2 year old B. I will set up a appointment with a nutrition expert C. Force him to eat all the food on his plate D. You need to follow up with a gastroenterologist - Correct answer A. This is normal development for a 2 year old The mother of a 2 month old calls and states her child was in the Emergency room and has been diagnosed with colic . The nurse explains that colic is ? A. Self limiting resolves around 12-16 weeks B. Common in breast fed infants C. Intolerance to soy based formula D. Related to constipation - Correct answer B. Self limiting resolves around 12-16 weeks What statements are true regarding the back to sleep campaign to prevent Sudden Infant Death Syndrome? Select all that apply A. The back to sleep campaign has dramatically reduced the incidence of SIDS B. the child should be placed prone C. the child should be placed supine D. With the back to sleep campaign the child is at greater risk for plagiocep - Correct answer A. The back to sleep campaign has dramatically reduced the incidence of SIDS C. the child should be placed supine D. With the back to sleep campaign the child is at greater risk for plagiocep The nurse is assessing a 3 year old what would be appropriate action to prepare the child for the exam ? A. Don't allow the child to hold a toy it may annoy the doctor B. allow the child to sit on parents lap C. Use medical terminology so the child doesn't understand the exam D. Separate the child from the parent - Correct answer B. allow the child to sit on parents lap A 12 month old is at her well child visit .What abnormal finding needs to be reported to the provider? A. Birth length Birth length has increased by 50% B. 8 teeth have erupted D. Weight below 5th percentile for height and age - Correct answer D. Weight below 5th percentile for height and age What statement by a 4 year old mom indicates that further teaching is needed? Select all that apply A. I don't put him in a car seat anymore he cries to much B. I stay with him when he is bathing C. All of our medications are in locked cabinets D. He is able to warm up his food in the microwave - Correct answer A. I don't put him in a car seat anymore he cries to much D. He is able to warm up his food in the microwave A patient on an intravenous opioid analgesic has become apneic. The nurse should implement which interventions FIRST ? A. Call parents to wake child B. Administer epinephrine C. Prepare to calm the child as analgesia is reversed D. Administer the prescribed naloxone (Narcan) dose by slow IV push. - Correct answer D. Administer the prescribed naloxone (Narcan) dose by slow IV push Augmentin 150mg is to administered every 8 hours po to a child weighing 33lbs Available is 125mg/5ml. How much much would you give per dose? 10ml 5ml 15ml 6ml - Correct answer 6ml The mother of a 4 month old states she is not immunizing her child because she is afraid of the child will develop Autism .The nurses best response would be ? A. Get some of the vaccines and see how he does B. There is no indication that there is any correlation between vaccines and autism C. I am calling Children's Services this is neglect D. I would do the same thing - Correct answer B. There is no indication that there is any correlation between vaccines and autism A 12 month old child is in the being sent up from the Emergency Room with a fever and cough for 2 days the nurse suspects influenza .The charge nurse is following best practice by? A. Allow child to go to the playroom as long as they wash there hands B. Place child in a private room C. Place child in a room with another child that has the same symptoms D. Place child in a warm mist tent - Correct answer B. Place child in a private room A 6 month old comes in with otitis media .The PCP prescribes Zithromax 10mg /kg for the first day. Available 100mg/5ml .How many ml will the child get her weight is 22lb 3ml 0.5ml 1ml 5ml - Correct answer 5ml The nurse is doing a assessment on a 4 year old with a viral infection and temperature 103.2 she recognizes a opportunity to educate the parents by which statements? Select alll that apply A. I will give her children's Motrin B. I will increase her fluids and make sure she is not dehydrated C. I will give her the adult tylenol it is cheaper D. I will wrap her up in blankets to help break her fever. That what my grandma said to do - Correct answer C. I will give her the adult tylenol it is cheaper D. I will wrap her up in blankets to help break her fever. That what my grandma said to do The nurse is administering a intramuscular injection (IM) to a 1 year old .What site should the nurse use? ventrogluteal Deltoid Vastus lateralis Dorsal gluteal - Correct answer Vastus lateralis A infant just had blood drawn the nurse has determined that he is in pain by the following observations ? Rigid body Silent withdrawn Smiling - Correct answer Rigid body While giving discharge instructions to the father of a child that was diagnosed with Asthma the nurse reviews all the following to prevent exacerbation ? Select all that apply A. get yearly flushot B. Keep rescue inhalers available at all times C. Remove molds and dust mites from the home. D. avoid flu shot if symptomatic - Correct answer A. get yearly flushot B. Keep rescue inhalers available at all times C. Remove molds and dust mites from the home. A mom cries out that her daughter is will not wake up and has stopped breathing. The nurse goes in the room the 7 month old HR is 80 the nurse has hit the button for help.What does she do next? A. Administer oxygen via face mask 4liters B. Administer 100% oxygen via bag valve mask C. administer oxygen via nasal canula 2liters D. give a albuterol treatment - Correct answer B. Administer 100% oxygen via bag valve mask A 8 year old has a 3 day history of vomiting and diarrhea he is difficult arouse BP 76/48 this would be classified as ? normal blood pressure hypertension bradycardia hypotension - Correct answer hypotension CPR is initiated in a 6 year old child with a non palpable blood pressure. The nurse was unable to start a IV .What would the nurse expect to occur NEXT? A. Intramuscular needle access B. no access needed C. Intraosseous Needle access D. Subcutanous needle access - Correct answer C. Intraosseous Needle access The nurse is assessing vital signs on a 12 month old the respiratory rate is 30 breaths per minute .Based on these findings the nurse? A. Administers oxygen B. administers a breathing treatment C. Documents findings D. Notifies the doctor - Correct answer C. Documents findings A single mom states she is very tired and the baby cries she is afraid she is "going to lose it" the nurses best response would be? A. just stick it out things will get better B. drink some coffee and hold the baby C. place the baby in the crib let her cry and call a family member or friend to help care for the baby A. Inappropriate parental concern for the degree of injury B. Inappropriate response of child C. Absence of parents for questioning about child's injuries D. Incompatibility between the history and injury observed - Correct answer D. Incompatibility between the history and injury observed The father of a 12-year-old child tells the nurse that he is concerned about his son getting "fat." His son is at the 50th percentile for height and the 75th percentile for weight on the growth chart. What is the most appropriate nursing action? A. Explain that this is typical of the growth pattern of boys at this age B. Reassure the father that his child is not fat C. Reassure the father that his child is just growing D. Suggest a low-calorie, low-fat diet - Correct answer A. Explain that this is typical of the growth pattern of boys at this age A 12-year-old male has short stature and appears depressed . What should the nurse be the most concerned about? A. Child's self-esteem B. Proper administration of thyroid hormone C. Proper administration of human growth hormones D. Helping child understand that he has not completed growing - Correct answer A. Child's self-esteem Which is descriptive of bulimia during adolescence? A. Feelings of elation after the binge-purge cycle B. Profound lack of awareness that the eating pattern is abnormal C. Weight that can be normal, slightly above normal D. Strong sense of control over eating behavior - Correct answer C. Weight that can be normal, slightly above normal Which is an important consideration when the nurse is discussing enuresis with the parents of a young child? Select all that apply A. Organic causes that may be related to enuresis should be considered first B. Enuresis is more common in boys than in girls C. Enuresis is neither inherited nor has a familial tendency. D. Psychogenic factors that cause enuresis persist into adulthood - Correct answer A. Organic causes that may be related to enuresis should be considered first B. Enuresis is more common in boys than in girls The nurse is assisting the family of a child with a history of encopresis. Which should be included in the nurse's discussion with this family? A. Suggest the use of stimulant laxatives daily. B. Reassure the family that most problems are resolved successfully, with some relapses during periods of stress. C. Instruct the parents that the child will probably need to have daily enemas. D. Instruct the parents to sit the child on the toilet at twice-daily routine intervals. - Correct answer B. Reassure the family that most problems are resolved successfully, with some relapses during periods of stress. A school nurse is conducting a class with adolescents on suicide. Which true statement about suicide should the nurse include in the teaching session? A. Gay and lesbian adolescents are at a particularly high risk for suicide B. A sense of hopelessness and despair are a normal part of adolescence C. Problem-solving skills are of limited value to the suicidal adolescent. D. Previous suicide attempts are not an indication of risk for completed suicides - Correct answer A. Gay and lesbian adolescents are at a particularly high risk for suicide The nurse is correctly educating a patient on the use of his inhalers when she tells the patient to A. hold his/her breath for 60 seconds after inhaling the medication. B. only take his long acting steroid inhaler when he has symptoms. C. take his bronchodilating (albuterol) inhaler first. D. wait 2 seconds between puffs. - Correct answer C. take his bronchodilating (albuterol) inhaler first. The nurse reviews the chart for a 4 month-old patient 8.1kg with RSV patient has increased wheezing and mild retractions. Which of the following interventions would be MOST effective? A. Administer albuterol by nebulization. B. Administer Motrin 52mg C. Administer amoxicillin 200mg every 12 hours D. Fluid bolus 20ml/kg D5 NACL bous - Correct answer A. Administer albuterol by nebulization A 15 year-old patient is treated for an asthma attack following exposure to tobacco smoke at a friend's home. The BEST advice the nurse can give is A. "avoidance of known triggers is the best way to prevent attacks." B. "it will be a good practice to take your preventive medications after going to your friend's house the next time." C. "your friend's parents need to be advised that they cannot smoke in their home when you come to visit." D. "take a extra dose of your long acting inhaler before you go over to your friends house" - Correct answer A. "avoidance of known triggers is the best way to prevent attacks." Which of the following is a true statement about pertussis? A. Adults caring for children should receive a booster vaccine for pertussis. B. Children with pertussis develop a cough that sounds like a seal barking. C. Pertussis has been almost completely eradicated in the United states D. Pertussis may lead to permanent lung problems - Correct answer A. Adults caring for children should receive a booster vaccine for pertussis. D. Pertussis may lead to permanent lung problems A 20 month-old presents for treatment of stridor associated with croup. The nurse anticipates a STAT order from the physician for acetaminophen (Tylenol) levalbuterol (Xopenex) prednisone (Prelone) racemic epinephrine (Vaponephrine) - Correct answer racemic epinephrine (Vaponephrine) A nurse is caring for a 3 month old infant diagnosed with respiratory syncytial virus (RSV). Which of the following manifestations concerns the nurse the most? Select all that apply A. congested moist cough. B. expiratory wheezing than decreased air moment C. respiratory rate of 34 D. respiratory grunting. - Correct answer B. expiratory wheezing than decreased air moment D. respiratory grunting. Which of the following manifestations distinguishes croup from other respiratory disorders? A. barking cough and stridor. B. cough and nasal drainage. C. nasal flaring and grunting. D. wheezing and retracting. - Correct answer A. barking cough and stridor A 5 month old infant is admitted for treatment of respiratory syncytial virus (RSV). Which of the following alerts the nurse to EARLY signs of increasing distress? Rales oxygen saturation of 94% on room air. A. "Axillary temperatures are more accurate than oral temperature or rectal temperatures." B. Rectal temperatures tend to be lower than oral or axillary temperatures." C. "When taking a rectal temperature, advance the thermometer slightly past where resistance is felt." D. "For a tympanic temperature, pull the pinna down and back before inserting the probe into the ear." - Correct answer D. "For a tympanic temperature, pull the pinna down and back before inserting the probe into the ear." A 4 year old is admitted with pneumonia the orders read ibuprofen 5mg/kg every 6hours for a temp above 101.2 The medication is labeled 100mg in 5ml. The child has a temp of 102.2 last dose was 8 hours ago patients weight 44 lbs.Please calculate how many milliliters the child will receive. 5ml 4.5ml 6.5ml 10ml - Correct answer 5ml Ceftriaxone 50 mg/kg/dose IM every 24 hrs is ordered for a 12 week old female that weighs 14 LBS diagnosed with pneumonia . What is correct regarding this medication administration. Select all that apply 318 mg will be administered 700 mg will be administered 25 gauge needle will be used 20 gauge needle will be used - Correct answer 318 mg will be administered 25 gauge needle will be used Tamiflu is ordered for a child with influenza symptoms the dose ordered is 45 mg bid available 6mg per ml how many milliliters would the child receive each dose ? 3.5ml 6ml 15ml 7.5ml - Correct answer 7.5ml A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The nurse should plan which priority intervention when caring for the child? A. Take the child frequently to the playroom to play with other children. B. Maintain frequent touch and eye contact with the child. C. Place child in a room with a roommate of the same age. D. Maintain a structured routine and keep stimulation to a minimum - Correct answer D. Maintain a structured routine and keep stimulation to a minimum What is the source used to classify sexual development of an child? Tanner Staging Target Staging Ericson Staging Freud Staging - Correct answer Tanner Staging A child has gastroenteritis the diet that is recommended after clear liquids is ? Bananas, rice ,applesauce and toast milk and cookies prunes ,cottage cheese ,hamburger Chicken nuggets and fries - Correct answer Bananas, rice ,applesauce and toast An infant is brought to the emergency department with dehydration. Which physical assessment finding does the nurse expect? Select all that apply weight loss Tachycardia Poor skin turgur Brisk Capillary refill - Correct answer weight loss Tachycardia Poor skin turgur Which pathogen that frequently causes acute diarrhea in very young children if they are not immunized ? Rotavirus Shigella organisms Influenza Giardia organisms - Correct answer Rotavirus A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. He is still vomiting and lethargic. What should therapeutic management of this child begin with? Water only Oral replacement fluids Intravenous (IV) fluids NACL Administration of antidiarrheal medication - Correct answer Intravenous (IV) fluids NACL Which therapeutic management treatment is implemented for children with Hirschsprung disease? Daily enemas Surgical removal of affected section of bowel Permanent colostomy Low-fiber diet - Correct answer Surgical removal of affected section of bowel Low-fiber diet A 4-month-old infant has gastroesophageal reflux (GERD) but is thriving without other complications. Which should the nurse suggest to minimize reflux? Select all that apply Place in Trendelenburg position after eating. Thicken formula with rice cereal Feed baby more often Give continuous nasogastric tubes fee - Correct answer Thicken formula with rice cereal Feed baby more often The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What nursing care should be included?. Elevate the head but give nothing by mouth Feed glucose water only. Elevate head after feeding Don't Suction Infant - Correct answer Elevate the head but give nothing by mouth What is the name of one segment of bowel within another called? Herniatnion Atresia Stenosis Intussusception - Correct answer Intussusception Which is true concerning hepatitis B? Select all that apply A. Hepatitis B can be prevented by HBV vaccine B. Hepatitis B can be transferred to an infant from holding the child. C. Principal mode of transmission for hepatitis B is fecal-oral route D. Principal mode of transmission for hepatitis B is infected body fluids - Correct answer A. Hepatitis B can be prevented by HBV vaccine D. Principal mode of transmission for hepatitis B is infected body fluids The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot? A. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy B. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy C. She can drink milk but I will read the labels on ice cream D. Fresh vegetables are ok but I will read the label on any dressings that may be added - Correct answer A. She can eat anything but wheat bread A 19 year old just delivered a baby in the Emergency room. She stated that she did not know she was pregnant and did not receive prenatal care.The child is cyanotic ,sunken abdomen and bowel sounds are heard in the chest .The nurse is concerned the child may have what condition? Hiatal Henia Diaphragmatic Hernia Abdominal Hernia Umbilical Hernia - Correct answer Diaphragmatic Hernia Umbilical Hernia is seen in a 2 month old boy the mom wants to know what will be done the nurse responds by stating ? A. Push on his umbilicus every 4 hours to promote closure B. Place a coin on his umbilicus and wrap it tight C. He will be scheduled for surgery next week D. Spontaneous closure usually occurs 3-4 (most by 1yr.) - Correct answer D. Spontaneous closure usually occurs 3-4 (most by 1yr.) A 4 week old infant is not feeding well and when examined there is white coating in the oral in the mouth .The nurse suspects thrush the mom asked how is this treated the nurse answers by stating which of the following ? Select all that apply A. Wash and sterilize nipples and pacifiers B. The child has yeast infection oral nystatin will be used C. Amoxicillin to the oral mucosa D. Antibiotics to the mothers breast if nursing - Correct answer A. Wash and sterilize nipples and pacifiers B. The child has yeast infection oral nystatin will be used A child complains of abdominal pain,and rebound tenderness, increased WBC's and left shift .The nurse knows the patient presents with the most common reason for abdominal surgery in children? Bowel obstruction Crohn's disease Appendicitis Irritable bowel syndrome - Correct answer Appendicitis Which drug is used to maintain the patency of the patent ductus arteriosus in infants with transposition of the great vessels? Prostaglandin E. Digoxin Antibiotics Diuretics - Correct answer Prostaglandin E. What medication is used to help close patent ductus ateriosus in neonates Lasix Digoxin Indomethacin Prostaglandin E. - Correct answer Indomethacin A 10-month old with heart failure weighs 10kg. Digoxin (Lanoxin) is prescribed as 10mcg/kg/day to be given every 12hours. How much is given each dose? 100mcg 10mcg 50 mcg 500mcg - Correct answer 50 mcg A nurse is caring for a child who has undergone a cardiac catherization .During the assessment the nurse notices the cath dressing is saturated with blood .What does the nurse do first? A. Call the doctor stat B. Call the cath lab since the child will be returning C. Apply a bulky dressing over the catherization site D. Apply direct pressure 1 inch above the puncture site - Correct answer D. Apply direct pressure 1 inch above the puncture site A child is born with a ventricular septal defect the nurse know that blood will be shunted left to right right to left through the aorta through the atria - Correct answer left to right When caring for a child with probable appendicitis, the nurse should be alert to recognize that which condition or symptom is a sign of perforation? Anorexia Bradycardia Sudden relief from pain Decreased abdominal distention - Correct answer Sudden relief from pain Which should be the major consideration when selecting toys for a child who is cognitively impaired? Ability to provide exercise Age appropriateness Ability to teach useful skills Safety - Correct answer Safety What are appropriate interventions to facilitate socialization of the cognitively impaired child? A. Provide peer experiences B. Provide age-appropriate toys and play activities C. Avoid exposure to strangers who may not understand cognitive development. D. Emphasize mastery of physical skills because they are delayed more often than verbal skills - Correct answer A. Provide peer experiences A 6 year old with Leukemia has been admitted to the hospital. He is experiencing a lot of pain. The child asks the nurse if the pain will ever go away. The nurse should make which BEST response? A. "The pain will go away if you want it to '' B. 'Try not to think about it the more you think the worse it is'' C. ''I know it must hurt tell me when it does and I will try to make it hurt a little less'' D. ''Every time it hurts , press the call bell and I will give you something to make it go all away'' - Correct answer C. ''I know it must hurt tell me when it does and I will try to make it hurt a little less' A clinic nurse is instructing the parent of an HIV (Human Immunodeficiency Virus) infected child regarding immunizations. The nurse should provide which instructions to the patient? A. The yearly inactivated influenza vaccine will need to be given after 6 months of age as a split dose B. Expose your child to various people so that he can build up his immune system C. The patient is not given any vaccines D. The western blot test to confirm HIV needs to be performed and results evaluated before immunizations - Correct answer A. The yearly inactivated influenza vaccine will need to be given after 6 months of age as a split dose The nurse is planning activity for a 4-year-old child with anemia. Which activity should the nurse plan for this child? A. Puppet play in the child's room B. A walk down to the hospital lobby C. Participation in dance activities in the playroom D. Explain to child that this is an expected side effect. - Correct answer B. Stop drug infusion immediately The nurse is teaching parents about prevention of urinary tract infections in children. Which factor contribute to risk of getting a urinary tract infection? Select all that apply A. Increased fluid intake B. Frequent emptying of the bladder C. Short urethra in young girls D. not wearing cotton underpants. - Correct answer C. Short urethra in young girls D. not wearing cotton underpants. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which finding in this newborn? A. The urethral opening is along the dorsal surface of the penis B. Absence of a urethral opening is noted. C. Penis appears shorter than usual for age. D. The urethral opening is along the ventral surface of the penis - Correct answer D. The urethral opening is along the ventral surface of the penis The nurse is conducting a staff in-service on newborn defects of the genitourinary system. Which describes the narrowing of the preputial opening of the foreskin? Phimosis Hypospadias Chordee Epispadias - Correct answer Phimosis A patient is diagnosed with Sickle cell anemia the nurse reconizes that the best way to avoid a crisis is to educate the parents on prevention .What would the nurse include in her teaching? Select all that apply A. Stay hydrated B. Increase oxygen demand with exercise C. Encourage immunizations D. Hypothermia - Correct answer A. Stay hydrated C. Encourage immunizations The mom of a 8 yr old that has been diagnosisd with Epistaxis states "I don't know what that means or what I am supposed to do the Penn State student nurse gives what information? Select all that apply A. The patient has a nose bleed B. Hold his head back if this occurs C. Lean forward so blood drains out D. May need packing - Correct answer A. The patient has a nose bleed C. Lean forward so blood drains out D. May need packing A hospitalized child that has a fever of 101.0 f or (38.3)c Tylenol 75 mg is ordered.The acetaminophen (Tylenol) is 80 mg per 0.8ml. How much will the nurse administer ? 0.75mg 1.5mg 2.5mg 3ml - Correct answer 0.75mg A child who weighs 20kg is to receive 8g of gamma globulin over 12 hours for the treatment of idiopathic thrombocytopenia purpura. The concentration is 8g in 300ml of normal saline.How many milliliters per hour will the child receive? 12ml 25ml 50ml 40ml - Correct answer 25ml The mother of a 9 year old child receiving chemotherapy is requesting medication for nausea The child is ordered 0.15mg /kg Odansetron (zofran) IV NOW The child weighs 74.7 lbs How many milligram of zofran will the child receive? 6mg 10mg 5mg 4mg - Correct answer 5mg A 12 year old female is complaining of sever back pain in the flank area and has a fever of 103.4.The renal sonogram shows rt sided backup obstruction and distention the child has most likely has what condition? Hypernephrosis Ureternephrosis Urethranephrosis Hydronephrosis - Correct answer Hydronephrosis The father of a 14 yr old girl brings his child in for swelling of his eyes, legs he states that she was ill with a strep infection 10 days ago but did not complete her antibiotics .The nurse takes her vitals and is concerned his BP is 164/98.The urine sample is tea colored.What are the symptoms associated with? Acute Glomerulonephritis Acute Ureternephtitis Congestive heart failure Hepatic failure - Correct answer Acute Glomerulonephritis A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The child's level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. What is the most appropriate nursing action? A. Discuss with practitioner what analgesia can be safely administered B. Discuss with parents the child's previous experiences with pain C. Explain that analgesia is contraindicated with a head injury D. Explain that analgesia is unnecessary when child is not fully awake and alert - Correct answer A. Discuss with practitioner what analgesia can be safely administered Which is the priority nursing intervention for an unconscious child after a fall? A. Perform neurologic assessment. B. Establish adequate airway. C. Monitor intracranial pressure. D. Determine whether a neck injury is present. - Correct answer B. Establish adequate airway. A 10-year-old boy on a bicycle has been hit by a car in front of the school. The school nurse immediately assesses airway, breathing, and circulation. What is the next nursing action A. Stabilize neck and spine B. Check scalp and back for bleeding C. Take blood pressure D. Place on side - Correct answer A. Stabilize neck and spine Which are clinical manifestations of increased intracranial pressure (ICP) in infants? Select all that apply Irritability Low-pitched cry Sunken fontanel bulging fontanelle - Correct answer Irritability bulging fontanelle The nurse has received report on four children. Which child should the nurse assess first?