While Making Rounds,the Nurse Enters a Room and Finds an Infant

question 11

Multiple Choice

While making rounds,the nurse enters a room and finds an infant patient's father violently shaking the infant.The father makes it appear as though the infant was choking.Upon further assessment,the nurse notes bruised areas on the infant's arms and legs.What priority action should the nurse take?

• A) Discussing what she witnessed with the infant's mother
• B) Discussing what she witnessed with the other nurses
• C) Reporting what she witnessed and assessed to child protective services
• D) Reporting what she witnessed and assessed to the local law enforcement agency

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Definitions:

Hypotension

A medical condition where blood pressure is much lower than normal, potentially leading to symptoms like dizziness or fainting.

Furry Tongue

A condition characterized by an abnormal coating on the tongue’s surface, often due to poor oral hygiene, causing it to appear "furry."

Wheezing

A high-pitched whistling sound produced during breathing, often resulting from an obstructed airway.

Rhonchi

Low-pitched, rattling lung sounds that suggest blockage or secretion in the large airways, often heard in patients with bronchitis or pneumonia.