Nokea
History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
- A. Ask the healthcare provider to prescribe a nonsteroidal anti-inflammatory drug (NSAID)
- B. Have one of the parents hold the baby
- C. Perform guided imagery
- D. Consult a child life specialist
- E. Encourage the baby's mother to breastfeed the baby
- F. Wait 1 hour, reassess, and give medication if the FLACC score remains elevated
- G. Request a prescription for an opioid
Correct Answer: B,D,G
Rationale: NSAIDs, parental holding, child life consultation, and opioids (if severe) are appropriate. Guided imagery is too advanced, breastfeeding is contraindicated (NPO), and delaying treatment is inappropriate.
You may also like to solve these questions
Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
- A. Variability of fetal heart rate.
- B. Station of presenting part.
- C. Level of pain sensation.
- D. Maternal blood pressure.
Correct Answer: D
Rationale: Monitoring maternal blood pressure detects hypotension from epidural-induced vasodilation, preventing reduced placental perfusion.
A client who is in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?
- A. Notify the operating room team.
- B. Administer a fluid bolus of 500 mL.
- C. Administer oxygen via face mask.
- D. Place the client in Trendelenburg.
Correct Answer: D
Rationale: Trendelenburg positioning relieves umbilical cord compression, preventing fetal hypoxia in this emergency.
A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse implement next?
- A. Begin prescribed intravenous antibiotic administration.
- B. Schedule the child for a STAT magnetic resonance imaging (MRI) of the neck.
- C. Obtain bedside trays for intubation or tracheotomy by the healthcare provider.
- D. Provide a nebulizer treatment with bronchodilators.
Correct Answer: C
Rationale: Symptoms suggest epiglottitis, requiring immediate airway management. Intubation/tracheotomy trays are critical to address potential airway obstruction.
The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for client with preterm labor. The IV bag contains 'Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.' How many mL/hour should the nurse set the infusion pump?
- A. 450 mL/hour
Correct Answer: A
Rationale: For 6 grams in 20 minutes, 150 mL (6 ÷ 0.04 g/mL) is needed. Infusion rate is 150 mL ÷ 20 min × 60 = 450 mL/hour.
During the admission procedure of a school age child, the child states, 'I'm going to have an operation.' Which response is best for the nurse to provide to this child?
- A. Tell me what an operation is.'
- B. We're going to do everything we can to take very good care of you.'
- C. I'm glad your mother told you why you were coming to the hospital.'
- D. Are you scared?'
Correct Answer: A
Rationale: Asking the child to explain their understanding assesses knowledge, addresses misconceptions, and supports age-appropriate communication.