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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Group therapy can be beneficial for individuals with substance abuse issues as it provides support, reduces isolation, and promotes healthy coping mechanisms. However, it is not the primary intervention for ensuring the health of the baby in a pregnant client on methadone.
Choice B rationale
Discontinuing methadone abruptly is dangerous and can lead to withdrawal symptoms, which can harm both the mother and the fetus. It is important to continue methadone treatment under medical supervision to prevent complications.
Choice C rationale
Genetic testing protocols are important for identifying potential genetic disorders but do not directly address the immediate health needs of a baby born to a mother on methadone treatment.
Choice D rationale
Starting a prenatal care plan as soon as possible is crucial for monitoring the health and development of the fetus, managing the mother's methadone treatment, and providing necessary interventions to ensure the baby's well-being. It is the best approach to ensure a healthy pregnancy.
Correct Answer is A
Explanation
Choice A rationale
Maternal blood pressure is crucial to monitor post-epidural anesthesia, as hypotension is a common side effect. Prompt detection and management of low blood pressure are vital to ensuring maternal and fetal well-being, making this the most important assessment.
Choice B rationale
Monitoring pain sensation helps determine the effectiveness of the epidural and the level of anesthesia. However, it is secondary to monitoring for hypotension, which can have more immediate and severe consequences.
Choice C rationale
The station of the presenting part is important for labor progression assessment but not as critical as monitoring for hypotension, which can significantly impact both the mother and fetus.
Choice D rationale
Fetal heart rate variability is vital, but immediate maternal hypotension management takes precedence, as it directly affects fetal oxygenation. .
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