A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

Administer a cathartic suppository 30 min prior to scheduled defecation times.

Encourage a maximum fluid intake of 1,500 mL per day.

Increase the amount of refined grains in the client's diet.

Provide the client with a cold drink prior to defecation.

Answer and Explanation

The Correct Answer is A

A. Correct. Administering a cathartic suppository can help stimulate bowel movement and facilitate a bowel-training program, particularly for individuals with altered bowel function due to spinal cord injury.

B. Incorrect. Adequate fluid intake is important, but limiting fluid intake is not typically recommended for clients with spinal cord injuries.

C. Incorrect. Refined grains are not specifically indicated for promoting bowel function. A balanced diet with sufficient fiber is more appropriate.

D. Incorrect. Providing a cold drink prior to defecation might not have a significant impact on bowel function and is not a commonly recommended intervention.

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Correct Answer is B

Explanation

A. Incorrect. Bulging fontanels are not typically associated with withdrawal from maternal methadone use. They might indicate increased intracranial pressure or other conditions.
B. Correct. Hypertonicity, or increased muscle tone, is a common sign of neonatal withdrawal from opioids such as methadone. It can manifest as increased resistance to passive movement.
C. Incorrect. Bradycardia is not a common withdrawal symptom from maternal methadone use. Neonates withdrawing from opioids might experience tachycardia, not bradycardia.
D. Incorrect. Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to withdrawal from methadone. It can be related to immature peripheral circulation.

A. “I try to respond to the baby quickly so she doesn't cry very long." B. "I have several friends who come by to help out with the baby." C. "I want to meet other parents to see if they are going through the same things." D. “I think the baby should be sleeping through the night by now”

Correct Answer is D

Explanation

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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A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal?

Correct Answer is B

Explanation

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?

Correct Answer is D

Explanation

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