A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as a possible indicator of inhibition of parental attachment?
"I don't need the bath demonstration. I know how to do it.".
"Do you think you could keep him in the nursery for the next feeding so I can get some sleep?.".
"I just wish he had more hair. I'm going to have to keep a hat on his head till he grows some.".
"He's got my husband's nose, that's for sure.".
The Correct Answer is C
Choice A reason:
This statement does not indicate inhibition of parental attachment. The client may have prior experience or knowledge of bathing a newborn and may not need the demonstration. The nurse should respect the client's autonomy and confidence in this skill.
Choice B reason:
This statement does not indicate inhibition of parental attachment. The client may be exhausted from the labor and delivery process and may need some rest to recover. The nurse should support the client's request and ensure that the newborn is well cared for in the nursery.
Choice C reason:
This statement indicates inhibition of parental attachment. The client expresses dissatisfaction with the newborn's appearance and implies that the newborn is not attractive enough. The nurse should explore the client's feelings and expectations about the newborn and provide reassurance and education about normal variations in newborn features.
Choice D reason:
This statement does not indicate inhibition of parental attachment. The client recognizes a family resemblance in the newborn and expresses a positive connection with the newborn and the partner. The nurse should acknowledge the client's observation and encourage further bonding with the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
Choice A reason:
Moro is a newborn reflex that occurs when the baby is startled by a loud sound or movement. The baby will cry, throw back his or her head, and then pull his or her limbs into the body. This reflex lasts until the baby is about 2 months old.
Choice B reason:
Rooting is a newborn reflex that starts when the corner of the baby's mouth is stroked or touched. The baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This helps the baby find the breast or bottle to start feeding. This reflex lasts about 4 months.
Choice C reason:
Gag is a newborn reflex that prevents the baby from choking on foreign objects. The baby will cough, gag or spit out anything that touches the back of the throat or the roof of the mouth. This reflex is present throughout life.
Choice D reason:
Running is not a newborn reflex. It is a voluntary movement that develops later in childhood. Choice E reason:
Babinski is a newborn reflex that occurs when the sole of the foot is stroked from heel to toe. The baby will fan out and curl up the toes and twist the foot inward. This reflex lasts until the baby is about 12 months old.
Choice F reason:
Stepping is a newborn reflex that occurs when the baby is held upright with his or her feet touching a solid surface. The baby will appear to take steps or dance. This reflex lasts about 2 months.
Choice G reason:
The crawling reflex is a developmental milestone observed in infants around 6-8 months of age. It involves the baby moving on their hands and knees, often starting with a belly-crawling motion. Unlike newborn reflexes, this skill is learned and requires muscle coordination and strength.
Choice H reason:
Standing with support is a developmental milestone typically achieved by infants around 9-12 months. In this skill, the baby pulls themselves up to a standing position while holding onto furniture or a caregiver’s hands. It is a learned behavior reflecting increased muscle strength and balance, distinct from newborn reflexes.
Choice I reason:
The pincer grasp is a fine motor skill that usually develops between 8-12 months. It involves the baby using the thumb and index finger to pick up small objects. This ability is not a reflex but a learned skill that demonstrates improved hand-eye coordination and dexterity.
Correct Answer is C
Explanation
Choice A reason:
Transferring the newborn to the NICU is not the best action to take next, because it does not address the immediate problem of low blood sugar. The newborn may need to be transferred to the NICU later, depending on the cause and severity of the hypoglycemia, but the first priority is to raise the blood glucose level.
Choice B reason:
Calling the lab for a STAT blood glucose level is not the best action to take next, because it will delay the treatment of hypoglycemia. The glucometer reading is a reliable indicator of low blood sugar, and waiting for a lab confirmation will waste valuable time. The nurse should act on the glucometer reading and initiate treatment as soon as possible.
Choice C reason:
Initiating breastfeeding is the best action to take next, because it will provide the newborn with a source of glucose that can raise the blood sugar level quickly. Breastfeeding also has other benefits for the newborn, such as promoting bonding, providing antibodies, and reducing the risk of infection. Breastfeeding should be initiated within the first hour of life for all newborns, unless contraindicated.
Choice D reason:
Recognizing this as a normal reading and documenting it is not the best action to take next, because it is not a normal reading for a 2 hour old newborn. The normal range of blood glucose for a newborn is 40 to 150 mg/dL. A reading of 32 mg/dL indicates hypoglycemia, which can have serious consequences for the newborn's brain development and function. Hypoglycemia should be treated promptly and documented accordingly.
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