A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days.
The child begins to cry and cling to his mother when the nurse enters the examination room.
Which action should the nurse implement to get the child to cooperate?
Request extra staff to help with the nursing assessments.
Explain to the child the reasons an examination is needed.
Talk to the mother and gradually focus on the child's toy.
Complete the assessment while allowing the child to cry.
The Correct Answer is C
Choice A rationale
Requesting extra staff to help with the nursing assessments may not be the most effective approach. It could increase the child's anxiety due to the presence of more unfamiliar people in the room. The primary goal is to create a calm environment that helps the child feel safe and more cooperative.
Choice B rationale
Explaining the reasons for the examination to the child may not be effective for a preschooler who may not fully understand or be comforted by such explanations. Young children often require more tangible and immediate means of reassurance and distraction.
Choice C rationale
Talking to the mother and gradually focusing on the child's toy is a practical approach. This strategy helps build rapport with both the mother and the child, and using the toy as a focal point can distract and comfort the child, making the examination process less intimidating and more cooperative.
Choice D rationale
Completing the assessment while allowing the child to cry may not be ideal. It can increase the child's distress and make the assessment more challenging. Addressing the child's emotional needs by providing comfort and distraction can lead to a more successful and less stressful examination.
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Correct Answer is B
Explanation
Choice A rationale
The client has a hemoglobin level of 12 g/dL and a hematocrit of 34%, which are within normal ranges for a postpartum woman. A blood transfusion is typically indicated for severe anemia or significant blood loss, neither of which is suggested by these lab results. Therefore, a blood transfusion is not warranted in this case.
Choice B rationale
Rubella vaccination is indicated for a client who is non-immune to rubella, as indicated by the laboratory results. Rubella vaccination is important to protect the client from contracting rubella in future pregnancies, which can cause serious congenital defects. Since the client is not currently pregnant and not immune, vaccination can be safely administered postpartum to prevent future rubella infections.
Choice C rationale
Penicillin G potassium is an antibiotic that might be used for a client who is group B Streptococcus positive to prevent neonatal infection during delivery. However, this client is group B Streptococcus negative, so there is no indication for this antibiotic. There is no need to administer Penicillin G potassium in this scenario.
Choice D rationale
Hepatitis B immunoglobulin is used for newborns of mothers who are hepatitis B surface antigen positive to prevent perinatal transmission of the virus. Since the client's lab results indicate she is hepatitis B surface antigen negative, there is no need for Hepatitis B immunoglobulin. The client and her newborn are not at risk of hepatitis B transmission, so this intervention is not required. .
Correct Answer is D
Explanation
Choice A rationale
Iron is essential for preventing anemia, particularly in pregnant women, but it does not prevent neural tube defects like anencephaly. Iron supports overall maternal and fetal health but is not specific to preventing congenital anomalies.
Choice B rationale
Calcium is crucial for fetal bone development and maternal bone health, but it does not play a role in preventing anencephaly. Adequate calcium intake is important during pregnancy but is not linked to neural tube defect prevention.
Choice C rationale
Vitamin D is important for bone health and immune function but does not prevent neural tube defects. Sufficient vitamin D levels are necessary for the mother's and baby's health but are not related to anencephaly prevention.
Choice D rationale
Folic acid is the correct choice as it has been shown to prevent neural tube defects, including anencephaly and spina bifida. It is recommended that women of childbearing age take folic acid supplements before conception and during early pregnancy to reduce the risk of these congenital anomalies.
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