A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?
"Have you tried holding your infant skin-to-skin?"
"is your infant able to latch on during breastfeeding?"
"What is your infant's level of activity?"
"Have you considered joining a parents' support group?"
The Correct Answer is B
A) "Have you tried holding your infant skin-to-skin?":
While skin-to-skin contact can be beneficial for infant bonding and comfort, the priority for a postoperative infant following a cleft palate repair is to ensure adequate feeding. While skin-to-skin contact can promote bonding and provide comfort, it does not directly address the infant's ability to latch on during breastfeeding, which is crucial for nutritional intake and healing postoperatively.
B) "Is your infant able to latch on during breastfeeding?":
This question addresses the priority concern for the nurse, which is the infant's ability to effectively latch on during breastfeeding. Adequate latch is essential for proper nutrition and hydration, especially for an infant recovering from a cleft palate repair surgery. The nurse needs to assess whether the infant can latch on properly to ensure adequate feeding and support optimal healing.
C) "What is your infant's level of activity?":
While assessing the infant's level of activity is important for overall health and well-being, it is not the priority question in this scenario. The nurse's primary focus should be on assessing the infant's feeding ability and ensuring adequate nutritional intake postoperatively.
D) "Have you considered joining a parents' support group?":
Joining a parents' support group can be valuable for emotional support and sharing experiences, but it is not the priority question in this situation. The immediate concern is ensuring the infant's nutritional needs are being met, particularly in the context of breastfeeding challenges following cleft palate repair surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "I respect your right to choose to discontinue treatment."
While this statement acknowledges the client's autonomy and right to make decisions about their care, it does not directly address the nurse's commitment to honesty or transparency in discussing hospice care.
B) "I will have a hospice nurse come discuss this kind of care with you."
While involving a hospice nurse is a supportive action, it does not directly demonstrate the nurse's commitment to honesty or openness in discussing hospice care with the client.
C) "I will answer any questions you have about hospice care honestly."
This statement demonstrates veracity by explicitly stating the nurse's commitment to providing truthful and accurate information about hospice care. It reassures the client that they can trust the nurse to provide honest answers to their questions.
D) "I work with hospice services to help you transition to their care."
While this statement indicates the nurse's involvement in facilitating the transition to hospice care, it does not specifically address the nurse's commitment to honesty or truthfulness in discussing hospice care with the client.
Correct Answer is D
Explanation
A) Asking a staff member from another unit to complete the evaluation: While involving someone from another unit may offer an external perspective, it may not necessarily ensure impartiality. The evaluator should have direct knowledge of the nurse's performance to provide a fair assessment.
B) Focusing primarily on areas that need improvement: This approach may lead to a biased evaluation, as it overlooks the nurse's strengths and positive contributions. A comprehensive evaluation should consider both areas of strength and areas needing improvement to provide a balanced assessment.
C) Discussing the evaluation with the nurse manager: Consulting with the nurse manager about the evaluation could introduce bias, especially if the manager has preconceived notions about the nurse being evaluated. Peer evaluations should aim to be independent of managerial influence to maintain impartiality.
D) Linking the evaluation to predetermined standards: This is the correct approach to ensure impartiality in peer evaluation. By using predetermined standards or criteria, the evaluation process becomes objective and transparent. Evaluators can assess the nurse's performance against established benchmarks, reducing the influence of personal bias.
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