NSG 5544 Exam 3 Guided Notes | South College

Exam 3 Guided Notes
SECTION I: INJURY PREVENTION & ANTICIPATORY GUIDANCE
Case 1: Drowning Prevention – 15-Month-Old
A 15-month-old presents for a well-child visit. The family has an in-ground pool.
Step 1: Risk Assessment
List 3 developmental characteristics of a 15-month-old that increase drowning risk:
1. New mobility without judgment

 Walking/climbing → can ‫ الوصول‬pool quickly
2. Poor hazard awareness / impulsivity

 No understanding of danger
3. Top-heavy body + poor coordination

 Falls easily, can’t recover if head goes underwater
Step 2: Identify Highest Risk Injury Cause for Age
Most common cause of death in toddlers age 1–4: _ Unintentional injury (especially drown-
ing)
More specifically:Drowning is the leading cause of death in ages 1–4
Step 3: Evidence-Based Prevention Strategy
What is the MOST effective environmental control to prevent drowning?
Four-sided fencing with a self-latching, self-closing gate around the pool
(Not just a fence around the yard—must isolate the pool)
Clinical Reasoning:
Why is supervision alone insufficient?
 Drowning is:
 Silent
 Occurs in seconds
 Even attentive caregivers get distracted briefly
→ That’s enough time for a toddler to access water
Why are swim lessons NOT protective at this age?
 Toddlers lack cognitive and motor skills to reliably save themselves
 Skills are inconsistent
 May give false sense of security to parents
Management Plan:
 Parent education includes:
 Install 4-sided pool fencing with self-latching gate
 Constant “touch supervision” when near water
 Empty buckets/bathtubs immediately after use

,  Consider CPR training for caregivers

High-yield takeaway
The single most effective intervention is environmental control (fencing)—not supervision or
swim lessons.
Case 2: Increased Mobility – 12-Month-Old
Parents report climbing behavior.
Assessment
 Developmental stage: ___ Autonomy vs. Shame and Doubt __
Motor milestones expected at 12 months:
 Pulls to stand and cruises
 May take independent steps / beginning to walk
Environmental Risk Factors in This Age:
 Climbing onto furniture → fall risk
 Access to stairs
 Unsecured furniture/TVs (tip-over injuries)

Highest Priority Intervention:
Install safety gates and ensure close environmental control (especially stairs and climbing
hazards)
Explain Why
 Toddlers are:
o Highly mobile

o Curious

o Lack danger awareness

 Climbing dramatically increases fall risk, which is the most common injury at this age
 Environmental modifications are more reliable than supervision alone

High-yield takeaway
At 12 months, mobility + curiosity + no judgment = high fall risk → prioritize environmen-
tal safety (gates, anchoring, supervision)
Case 3: Firearm in Home – 3-Year-Old
Parents recently purchased a handgun.
Risk Assessment:
Why are preschoolers at high risk for firearm injury?
 Curious and exploratory → will handle objects they find
 No understanding of danger or consequences

,  Imitate adult behavior (seeing adults handle firearms)
 Impulsive with poor judgment and self-control
Safe Storage Criteria (List ALL components): 4
 Gun stored unloaded
 Gun locked (safe/lockbox)
 Ammunition stored separately
 Ammunition also locked
NP Counseling Script (Write your own 2–3 sentence counseling approach):
“Because children at this age are naturally curious and don’t understand danger, the safest way to
prevent injury is to store all firearms unloaded, locked, with ammunition locked separately. Even
brief access can be dangerous, so secure storage is critical at all times. I also recommend making
sure anyone your child visits has safe firearm storage in their home.”

High-yield takeaway
The most effective prevention is safe storage: locked, unloaded, ammo locked separately—
not relying on supervision or teaching the child alone.
SECTION II: CHILD ABUSE & MANDATORY REPORTING
Case 4: Spiral Humerus Fracture – 3-Year-Old
Caregiver story inconsistent.
Red Flag Injury Patterns:
1. Long bone fractures in non-ambulatory children
2. Posterior rib fractures
3. Metaphyseal corner (bucket-handle) fractures
(also high-yield: multiple fractures at different healing stages, bruising in non-mobile
child)
Why is a spiral fracture concerning?
 A spiral fracture implies a twisting mechanism
 In a young child (especially with an inconsistent history), this raises concern for non-ac-
cidental trauma because the mechanism often doesn’t match typical accidental injury
Mandatory Reporter Law:
What is your legal obligation?
You are legally required to report any suspicion of child abuse to Child Protective Services
(CPS)
 You do not need proof, only reasonable suspicion
 Failure to report can have legal consequences
Documentation:
Write an example of objective documentation:

, “3-year-old presents with right arm pain. Radiographs show spiral fracture of the humerus. Care-
giver reports injury occurred from a fall off couch; mechanism appears inconsistent with fracture
pattern. Child observed to be withdrawn during exam. No additional statements interpreted; di-
rect quotes documented when provided.”

High-yield takeaway
Pattern + history mismatch = suspect abuse → document objectively and report
Case 5: 9-Month-Old with Bruise
Bruise on lower back.
Fill In:
Bruising in a non-mobile infant is considered _____ Sentinel injury (highly suspicious for
non-accidental trauma)____.
What is the TEN-4-FACESp rule?
A clinical decision tool to identify bruising concerning for abuse:
 Torso
 Ears
 Neck
 4 → any bruise in a child <4 years old OR any bruise in <4 months old
FACESp:
 Frenulum
 Angle of jaw
 Cheeks
 Eyelids
 Sclera
 p = patterned bruising
👉 Bruising in these areas is highly concerning for abuse
Next Diagnostic Step:
Full non-accidental trauma (NAT) workup, including:
 Skeletal survey
 Consider head CT/MRI (especially <1 year)
 Labs if indicated (coagulation studies)
Why is calling CPS immediately NOT always first step?