Pediatric nursing · practice question
A 6-month-old infant in the pediatric clinic is being evaluated for pediatric injury prevention. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Which nursing action should the nurse take first?
Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026pediatric-nursing
Answer and explanation
Correct answer
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Why
First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
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