A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?
Holding the newborn in an en face position
Asking the father to change the newborn's diaper
Viewing the newborn's actions to be uncooperative
Requesting the nurse take the newborn to the nursery so she can rest
The Correct Answer is C
A. Holding the newborn in an en face position: This action promotes bonding between the mother and the newborn and is a positive interaction.
B. Asking the father to change the newborn's diaper: Involving the father in caregiving tasks fosters family involvement and bonding.
C. Viewing the newborn's actions to be uncooperative: This suggests a negative perception of the newborn's behavior, which could indicate potential issues with bonding or misunderstanding
infant cues, requiring the nurse's intervention.
D. Requesting the nurse take the newborn to the nursery so she can rest: While rest is important for the mother, separating the newborn from the mother could disrupt bonding and breastfeeding, so this action should be discussed further with the client to explore other options.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- Rationale for A: Following simple instructions indicates that the client is cooperative and may no longer pose a threat to themselves or others, which is a primary consideration for the removal of restraints. It shows the client's ability to understand and comply with directions, suggesting they are in a calmer state of mind. This behavioral change is a positive sign of regained control, making it safe to consider restraint removal.
- Rationale for B: While an apology may show remorse, it does not necessarily indicate that the client has calmed down or that they can safely interact without the restraints. Apologies can be driven by various motivations and do not reliably demonstrate a change in the risk of aggression.
- Rationale for C: A request to have restraints removed is not sufficient evidence of reduced risk. The client's desire to be unrestrained does not equate to a behavioral change that would justify removal, as it does not assess the client's current mental state or potential for aggression.
- Rationale for D: Maintaining eye contact is a positive social behavior but does not directly correlate with the client's potential for aggression or their ability to be safely managed without restraints. It is not a definitive indicator of the client's readiness to have restraints removed.
Correct Answer is A
Explanation
A.
A. Asymmetric lesions with variegated (multiple) colors are characteristic features of melanoma, a type of skin cancer. Asymmetry means one half of the lesion does not match the other half in size, shape, or color.
B. Scaly and red lesions may indicate other skin conditions such as eczema or psoriasis but are not specific to skin cancer.
C. Brown lesions with a wart-like texture may indicate seborrheic keratosis, a benign skin growth, rather than skin cancer.
D. Firm and rubbery lesions may indicate benign skin tumors such as fibromas or lipomas, rather than skin cancer.
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