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) Administer prescribed insulin:
Administering insulin is an essential aspect of managing type 1 diabetes mellitus, but before administering insulin, it's crucial to assess the client's current blood glucose level to determine the appropriate insulin dosage. Administering insulin without knowing the client's blood glucose level could lead to hypoglycemia if the blood glucose level is already low.
B) Check the calibration of the glucometer:
While it's important to ensure that the glucometer is calibrated correctly for accurate blood glucose readings, this step can be performed after obtaining the client's blood glucose level. Checking the calibration of the glucometer does not directly address the immediate need to assess the client's blood glucose level.
C) Obtain the client's capillary blood glucose level:
This is the most appropriate action to take first when providing morning care to a client with type 1 diabetes mellitus. Assessing the client's blood glucose level allows the nurse to determine the client's current glycemic status and make informed decisions about subsequent care, including insulin administration and breakfast provision.
D) Provide the client's breakfast:
Providing breakfast is an important aspect of morning care for a client with diabetes, but it should be done after assessing the client's blood glucose level. Depending on the client's blood glucose level, the nurse may need to adjust the timing or composition of the breakfast to ensure optimal glycemic control.
Correct Answer is C
Explanation
A) Vital signs flow sheet:
While vital signs are essential for assessing the client's health status, the home health agency typically focuses on the client's ongoing care needs rather than retrospective data such as vital sign trends.
B) Nursing admission assessment:
The nursing admission assessment provides valuable information about the client's initial condition upon admission to the acute care facility. However, the home health agency primarily requires information relevant to the client's current health status and ongoing care needs.
C) Current medications:
Providing the home health agency with a list of the client's current medications is essential for continuity of care. It allows the home health agency to ensure that the client receives the appropriate medications and dosages after discharge. This information helps prevent medication errors, adverse drug interactions, and omissions in the client's care plan. Additionally, the home health agency can use the medication list to reconcile medications and update the client's medication regimen as needed.
D) Nurses' notes:
While nurses' notes contain valuable information about the client's care during their stay in the acute care facility, they may not be immediately relevant to the home health agency's provision of care in the community setting. The focus of the home health agency is typically on the client's current status and needs rather than historical documentation.
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