A two-month-old infant is a direct admission to the pediatric ...

[jc611]

A two-month-old infant is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent life-threatening event). The physician is to see the infant to write medical orders.
 
  The nurse completes the nursing history and performs an assessment and finds no abnormal findings. While waiting on the physician, which activity can the nurse perform independently? 1. Place the child on an apnea monitor.
  2. Place the child on nasal cannula oxygen.
  3. Draw blood for arterial blood gases.
  4. Place the child on contact isolation.

Question 2

The nurse is caring for a child who has sickle-cell anemia and is in a painful crisis. The most effective nursing intervention for this child would be:
 
  1. Giving comfort measures, such as back rubs.
   2. Suggesting diversional activities, such as coloring.
   3. Administering pain medication.
   4. Preparing the child for painful procedures.

[LP]

Answer to Question 1

1
Rationale 1: This is appropriate monitoring of the infant.
Rationale 2: Oxygen is a dependent order except under emergency situations. There is no evidence the child needs oxygen.
Rationale 3: Lab tests are not an independent action.
Rationale 4: There is no indication of a respiratory infection. At this time, contact isolation is not indicated.
Global

Answer to Question 2

3
Rationale:
1. Comfort measures and diversional activities are not effective against severe pain in children. Comfort measures should be given to every child, and can be used after pain medication is given.
2. A child in severe pain is not capable of participating in or enjoying diversional activities.
3. Severe pain requires administration of pain medication for pain relief.
4. Preparing the child for painful procedures is not appropriate when the child is already in pain.