During a clinic visit, the practical nurse (PN) observes an infant sucking on a pacifier that is made from a bottle nipple and stuffed with cotton. What should the PM do?
Encourage the mother to use a one-piece pacifier.
Observe infant for difficulty in sucking.
Tell the mother that pacifiers can cause dental problems.
Compliment the mother for meeting her infant's needs.
The Correct Answer is A
A. Encouraging the mother to use a one-piece pacifier is the appropriate action as it reduces the risk of choking or ingestion of small parts and is safer for the infant.
B. Observing the infant for difficulty in sucking is important, but addressing the safety of the pacifier takes precedence.
C. Informing the mother about potential dental problems associated with pacifier use might be relevant but doesn't address the immediate safety concern of the makeshift pacifier.
D. Complimenting the mother for meeting her infant's needs doesn't address the potential safety risks associated with the homemade pacifier.
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Related Questions
Correct Answer is C
Explanation
A. Write an incident report about the bruises on the infant. - These areas might not be bruises; hence, writing an incident report without accurate information could be premature.
B. Review the labor and delivery record for birth trauma. - While important, it might not directly relate to the observed bluish-black areas.
C. Record the size and location of the areas in the infant's chart. - Documenting the observations is essential for tracking changes and informing other healthcare providers.
D. Notify the pediatrician of a possible bleeding problem with the infant. - Without further assessment, assuming a bleeding problem might be premature and unnecessarily alarming.
Correct Answer is B
Explanation
A. Requesting that the visitor leave is an unnecessary disruption that violates the client's right to privacy, autonomy, and personal relationships within her living space. Long-term care facilities are considered the residents' homes, and intimacy between consenting adults should be respected.
B. Exiting the room and quietly closing the door is the most appropriate initial action. It protects the client’s privacy, dignity, and autonomy. Residents in long-term care facilities retain their rights to consensual sexual expression and privacy, provided both parties are consenting and it does not infringe on the rights of others.
C. Asking when the nurse should return while the couple is still in bed compromises their privacy and can cause unnecessary embarrassment or discomfort for the client and her guest.
D. Reporting the incident to the family is a direct violation of the client's right to confidentiality and privacy. Unless the client is cognitively impaired and there is a concern regarding abuse or lack of consent, the nurse has no ethical or legal grounds to share the resident's private behavior with family members.
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