A nurse in a clinic is caring for a client who is pregnant and asks how she should help her 4-year-old son prepare for the new baby. Which of the following statements should the nurse make?
"Purchase a gift to give to your son from your baby."
"Make sure you are holding your baby when your son comes to visit you in the hospital
"Use medical terminology when teaching your son about your new baby "
"Surprise your son with a new bedroom after you bring the baby home.
The Correct Answer is A
A. "Purchase a gift to give to your son from your baby." This is an effective strategy to help a young child feel included and valued, easing the transition and reducing potential jealousy. It fosters a positive emotional connection between the older sibling and the newborn.
B. "Make sure you are holding your baby when your son comes to visit you in the hospital." This may unintentionally make the child feel replaced or left out. It’s better for the parent to be free to hug and reassure the older child during the initial visit.
C. "Use medical terminology when teaching your son about your new baby." Medical terms may confuse or overwhelm a 4-year-old. Simple, age-appropriate language is more effective in helping the child understand the upcoming changes.
D. "Surprise your son with a new bedroom after you bring the baby home." Sudden changes can be disorienting or upsetting for young children. Involving them in the transition process before the baby arrives helps foster a sense of control and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client calls the office multiple times per day to speak with their provider. This behavior may indicate anxiety or dependence, but it does not reflect rationalization, which involves making excuses to justify behavior.
B. The client states, "I only act this way because my partner makes me so angry." This is a clear example of rationalization, where the client is attempting to justify unacceptable behavior by blaming it on someone else rather than taking personal responsibility.
C. The client does not listen to the nurse during a discussion about their diagnosis. This may indicate denial or avoidance, not rationalization. The client may be overwhelmed and unwilling to accept the diagnosis.
D. The client reports that they get upset with their family members for "no apparent reason." This may suggest emotional dysregulation or projection, but it lacks the clear element of excuse-making that defines rationalization.
Correct Answer is A
Explanation
A. Flush the tubing with 30 mL of water every 4 hr. Flushing the tube regularly helps maintain patency, prevent clogging, and ensure that the feeding is delivered effectively. This is a standard practice in managing enteral feeding systems.
B. Check for gastric residual every 12 hr. Gastric residuals should typically be checked every 4 to 6 hours, or per facility protocol, especially in clients at risk for aspiration. Waiting 12 hours is too long and may delay identifying feeding intolerance.
C. Place enough formula in the container to last 18 hr. Open systems should have fresh formula added every 4 hours to reduce the risk of bacterial contamination. Leaving formula in the feeding bag for 18 hours exceeds safety guidelines and increases infection risk.
D. Maintain bed elevation at 20°. The head of the bed should be elevated to at least 30 to 45 degrees to reduce the risk of aspiration. A 20° elevation is insufficient and does not provide adequate protection during feeding.
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