The school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, which is the most appropriate action by the nurse?
1. Tilt the child's head back to help maintain an airway.
2. Place the child on the side to prevent aspiration.
3. Immobilize the neck, securing the head.
4. Try to rouse the child by gently shaking the shoulders.
3
Rationale 1: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck. The child is breathing, so the nurse should monitor the airway but should not move the child's head.
Rationale 2: If the child vomits, the nurse should utilize the log-roll technique to turn the child while keeping the head, neck, and spine in alignment.
Rationale 3: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilizing of the neck; securing the head; maintaining the patient in the supine position; and transferring from the stretcher with a backboard in place to the hospital bed. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage.
Rationale 4: Rousing the child by shaking could cause damage to the spinal cord.
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