Question

A nurse in a pediatric unit has received a change-of-shift report for four children. Which of the following children should the nurse assess first?

A. Child with a temperature of 99.8°F (37.7°C)
B. Child with a history of asthma
C. Child with a recent measles vaccination
D. Child with a complaint of severe abdominal pain

Answer 1

The child with severe abdominal pain should be assessed first because the intensity of the pain may indicate an urgent medical condition that could become life-threatening or cause significant harm. This takes precedence over mild fever, a history of asthma, or recent vaccination.

Step-by-step explanation:

The nurse in a pediatric unit should assess the child with a complaint of severe abdominal pain first. Severe pain is generally considered a high priority since it may indicate a more serious condition that requires immediate intervention. The other conditions, such as a mild temperature elevation, a history of asthma without current distress, and a recent vaccination, typically are not as urgent unless they are presenting with acute symptoms requiring immediate evaluation.

For instance, Michael, a 10-year-old with a high fever and severe headaches after consuming undercooked food, could be experiencing a serious infection that warrants immediate assessment. Likewise, Olivia, an infant with excessive crying, sensitivity to light, and vomiting, might be showing signs of a severe infection or another urgent medical condition.

In assessing urgency, nurses are trained to triage based on the potential for the condition to become life-threatening or cause significant harm, which is why severe abdominal pain takes precedence over the other scenarios provided.