A 3-week-old patient is hospitalized for surgical repair of hypertrophic pyloric stenosis. On the third postoperative day, the mother expresses concern that her infant vomited approximately one-fourth of his feeding. Which response by the nurse would be most appropriate at this time?
Plan for nurses to provide the feedings.
Report this finding to the health care provider.
Assure the mother that this is a normal finding.
Tell the mother it is all right to feel anxious.
The Correct Answer is B
Choice A rationale:
Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.
Choice B rationale:
Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.
Choice C rationale:
Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.
Choice D rationale:
Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The statement "I feel numb. I just can't believe this is happening”. reflects the emotional reaction of shock. Shock is a common initial response to distressing news, as the individual may find it difficult to process and accept the reality of the situation.
Choice B rationale:
Denial is the refusal to accept reality and is often accompanied by a lack of awareness or acknowledgment of the situation. The mother's statement does not demonstrate denial, as she acknowledges the situation but expresses disbelief.
Choice C rationale:
Anger is a stage of grief characterized by feelings of hostility and resentment. The mother's statement does not show anger, as she does not express any aggressive or hostile emotions.
Choice D rationale:
Depression involves feelings of extreme sadness, hopelessness, and low mood. The mother's statement does not directly convey depression; rather, it indicates a sense of disbelief and numbness.
Correct Answer is B
Explanation
Choice A rationale:
Avoid setting limits or establishing disciplinary guidelines is not appropriate. Children with cognitive impairment require structure and consistent boundaries to ensure their safety and development.
Choice B rationale:
Encouraging the child to socialize with same-aged children is important for their social and emotional development. Interaction with peers fosters communication skills and helps them integrate into society.
Choice C rationale:
Avoid discussing sexuality until the child is an adult may lead to misinformation and confusion. Addressing sexuality in an age-appropriate manner is vital to help the child develop a healthy understanding of their body and relationships.
Choice D rationale:
Encouraging delaying the child's entry into educational programs hinders their cognitive and intellectual growth. Early intervention and tailored educational programs are crucial for children with cognitive impairment to reach their full potential.
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