A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase" of maternal adjustment. Which of the following manifestations should the nurse expect?

Choice A Reason:

Posterior fontanel closed is incorrect, it is normal for the posterior fontanel to close earlier than the anterior fontanel, usually by 2 to 3 months of age.

Choice B Reason:

Anterior fontanel closed is correct. The anterior fontanel is the soft spot on the top of a baby's head, and it typically closes between 12 to 18 months of age. If the anterior fontanel is closed in a 4-month-old infant, it is considered an early closure, which can be a cause for concern. Early closure of the anterior fontanel can be associated with various underlying medical conditions, such as craniosynostosis (premature fusion of the skull bones) or dehydration.

Choice C Reason:

Plays with toes is incorrect. At 4 months of age, infants are typically developing their motor skills, and playing with their toes is a sign of normal development.

Choice D Reason:

Moves objects to mouth is incorrect. At this age, infants often explore their environment by bringing objects to their mouths as part of their sensory exploration and development.

Choice A Reason:

A. Applying water-soluble lubricant to the site is not typically necessary for routine site care. It may be used during the initial insertion of the tube or when changing the tube, but it's not part of routine site care.

Choice B Reason:

B. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy tube. Securing the tube to the cheek may cause irritation or discomfort for the child and is not a secure method to prevent dislodgment.

Choice C Reason:

C. Attaching an extension tube to the site's opening prior to use may be necessary for feeding or medication administration, but it is not specific to site care. Site care primarily involves cleaning and inspecting the site and ensuring that the tube is secure.

Choice D Reason:

Securing the tubing to the child's abdomen is correct. When providing site care for a child with a gastrostomy enteral tube, it's essential to ensure that the tube is secured properly to prevent accidental dislodgment. Therefore, the nurse should secure the tubing to the child's abdomen using appropriate medical tape or a securement device.