NORCET 3 - 2022 (Shif…: A Child complaining nausea and vomiting, what would be the nurse immediately action?

NORCET 3 - 2022 (Shift-2)

Child Health Nursing (Pediatrics)

Medium

Appeared in: NORCET 3 - 2022 (Shift-2)

Explanation

The immediate priority for a child who is actively vomiting is to maintain a patent airway and prevent aspiration (inhalation of vomit into the lungs).
Placing the child in a left lateral (side-lying) position is a critical safety measure that uses gravity to help vomit drain out of the mouth, keeping the airway clear.
This intervention, known as the recovery position, is the first and most important step a nurse should take to ensure the child's safety, and it does not require a physician's order.

Option B: Giving fluids orally to a child who is actively vomiting is often ineffective and can trigger more vomiting.
Option C: This is too vague and does not prioritize airway safety. A position the child finds comfortable, such as lying on their back, could dangerously increase the risk of aspiration.
Option D: This is an invasive procedure for treating severe dehydration. It is not the first-line immediate action and requires a physician's order.

Clinical Relevance

Nursing practice connection: Use the key finding related to Prioritization of nursing care for a pediatric patient with vomiting to guide bedside assessment, documentation, and the next nursing action.
Aspiration of stomach contents can lead to aspiration pneumonia, a serious and potentially fatal lung infection. Prioritizing airway management is a core nursing responsibility.
The recovery position is a fundamental first-aid and nursing skill that can be applied to any patient with a decreased level of consciousness or who is actively vomiting to protect their airway.
What if? If the child showed signs of severe dehydration (like being limp, having sunken eyes, and a very rapid pulse), the nurse's immediate actions would be to position for safety AND simultaneously call for immediate medical assistance to prepare for IV fluid resuscitation.

How to Approach the Question

First, identify the keywords in the question: 'child,' 'vomiting,' and especially 'immediate action'.
Recognize that 'immediate action' questions test your ability to prioritize. Apply the ABCs (Airway, Breathing, Circulation) framework to determine the most urgent need.
Analyze the primary risk of active vomiting, which is airway obstruction or aspiration. This makes 'Airway' the top priority.
Evaluate each option against this priority. The left lateral position directly protects the airway.
Eliminate the other options. Giving ORS and administering IV fluids address 'Circulation' (dehydration) but are secondary to securing the airway. Providing a 'comfortable position' is too vague and potentially unsafe.

Concept Tested & Keywords

Concept Tested: Prioritization of nursing care for a pediatric patient with vomiting.
Stem keywords: Child, nausea, vomiting, nurse, action
Lead-in keywords: immediately action
Clinical cues: Age/sex group narrows the expected diagnosis, intervention, or normal reference range.
Negative lead-in flag: false

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E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 112-114

E6 Text Book Of Pediatric Nursing 3rd Panchali Pal — Part 2 (pp 239-476 of 713) p. 147-149