A nurse is caring for an 8-month-old child who starts to cry when his parents leave. The nurse should make which of the following statements to the parents?
"At this age you should expect your child to be upset when you leave."
"Your child needs to rest."
will notify the provider of his behavior."
"Your child is responding to an overstimulating environment."
The Correct Answer is A
A. "At this age you should expect your child to be upset when you leave.": This statement provides normalcy to the parents' experience and reassures them that their child's reaction is typical for his age. It acknowledges the child's developmental stage and separation anxiety, helping to alleviate parental concerns.
B. "Your child needs to rest.": While rest is important for infants, this statement does not address the child's emotional needs or the parents' concerns about leaving their child. It may also minimize the significance of the child's distress.
C. "I will notify the provider of his behavior.": Notifying the healthcare provider may be appropriate if the child's distress continues or if there are concerns about the child's well-being, but this statement does not directly address the parents' concerns or provide guidance on how to manage the situation.
D. "Your child is responding to an overstimulating environment.": This statement suggests a possible cause for the child's distress but does not provide guidance or reassurance to the parents on how to address the situation or manage their child's reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will use powders & lotion on his skin around the harness clasps."
This statement indicates a misunderstanding. Powders and lotions should generally be avoided around the harness clasps because they can interfere with the proper fit of the harness and cause irritation or discomfort to the baby's skin.
B. “I will remove the harness daily, prior to giving the bath.”
This statement is incorrect. The Pavlik harness is typically not removed for bathing, as it needs to be worn continuously to maintain proper positioning of the hips and promote optimal healing. Removing the harness daily for bathing can disrupt the treatment process and delay progress.
C. "I will adjust the harness straps every day."
This statement indicates a misunderstanding. The harness should not be adjusted daily without guidance from the healthcare provider. The straps of the Pavlik harness are initially adjusted by the healthcare provider to ensure proper fit, and they should remain in place without frequent adjustments to maintain stability and effectiveness.
D. "I will check my baby's skin under the straps frequently."
This statement indicates an understanding of the teaching. It is essential for the mother to regularly check her baby's skin under the harness straps for any signs of irritation, redness, or pressure sores. Monitoring the skin closely allows for early detection of any issues that may arise from wearing the harness.
Correct Answer is D
Explanation
A. Place the infant in prone position.
This option is incorrect. Placing the infant in the prone position (lying on the stomach) could put pressure on the spinal lesion, potentially causing discomfort or complications. It's important to minimize pressure on the affected area in infants with spina bifida.
B. Cover the infant's lesion with a dry cloth.
This option is incorrect. While keeping the lesion clean and dry is important for preventing infection, simply covering it with a dry cloth may not provide adequate protection. Proper wound care techniques, such as using sterile dressings and cleaning the area with prescribed solutions, are typically necessary to prevent infection and promote healing.
C. Feed the infant through an NG tube.
This option is incorrect. While infants with severe forms of spina bifida may have difficulty feeding due to associated complications, such as difficulty swallowing or weak sucking reflexes, feeding through a nasogastric (NG) tube is not a standard intervention for spina bifida itself. Feeding methods would depend on the specific needs and abilities of the infant, and may involve breastfeeding, bottle-feeding, or other methods under the guidance of healthcare professionals.
D. Diapering over a low defect will keep the infant free from infection.
This option is correct. Diapering over a low defect (the opening in the spine caused by spina bifida) helps to keep the area clean and reduce the risk of infection. By properly covering the defect with a diaper, exposure to urine and feces, which can increase the risk of infection, is minimized. Additionally, regular diaper changes and proper hygiene practices are essential for preventing complications in infants with spina bifida.
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