A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse?

“I try to respond to the baby quickly so she doesn't cry very long."

"I have several friends who come by to help out with the baby."

"I want to meet other parents to see if they are going through the same things."

“I think the baby should be sleeping through the night by now”

Answer and Explanation

The Correct Answer is D

Choice A reason:

"I try to respond to the baby quickly so she doesn't cry very long." This statement is incorrect because it indicates the parent's sensitivity to the baby's needs and responsiveness to the baby's cues, which are positive signs of appropriate caregiving.

Choice B reason:

"I have several friends who come by to help out with the baby." This statement is incorrect because having a support system in the form of friends who help with the baby is a positive factor that can reduce stress and promote a healthy postpartum period.

Choice C reason:

"I want to meet other parents to see if they are going through the same things." This statement is incorrect because seeking social support and connecting with other parents can be beneficial in reducing feelings of isolation and stress during the postpartum period.

Choice D reason:

"I think the baby should be sleeping through the night by now is the correct statement "I think the baby should be sleeping through the night by now," as a manifestation of increased risk for child abuse. This statement may indicate unrealistic expectations or frustration from the parent regarding the baby's sleep patterns.

It is common for newborns to wake frequently during the night for feeding and care, and their sleep patterns can vary significantly in the early weeks and months of life. Unrealistic expectations or frustration about the baby's sleep habits can contribute to increased stress for the parent, which might increase the risk of child abuse or neglect.

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Correct Answer is D

Explanation

The correct answer is D. Remind the client to use the incentive spirometer.

Choice A rationale:

Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.

Choice B rationale:

Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.

Choice C rationale:

Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.

Choice D rationale:

Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.

A. Call in additional medical-surgical unit nursing care staff B. Act as a liaison between the facility and the media C. Determine the medical needs of incoming clients through the emergency department. D. Recommend to the provider specific acute care clients for discharge.

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: While additional staff may be needed, the primary focus during a mass casualty event is triage and immediate care. Choice B rationale: Media relations are important, but the nurse's priority is direct patient care. Choice C rationale: Assessing incoming clients and determining their medical needs is crucial for prioritizing care and allocating resources effectively. Choice D rationale: Discharging stable clients may be necessary in extreme circumstances, but it is not the immediate priority. The focus should be on providing care to the influx of injured patients.

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A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take

Correct Answer is C

Explanation

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