Pediatric nursing · practice question
A 6-month-old infant in the pediatric clinic is being evaluated for postoperative pain in a school-age child. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Which assessment approach should the nurse use first?
Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026pediatric-nursing
Answer and explanation
Correct answer
D. Screen for instability, then perform a focused assessment related to the presenting concern.
Why
Assessment begins with stability screening and focused data collection before invasive or delayed actions.
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