A 6-month-old patient with a plaster spica cast is being breastfed by her mother. Which action by the mother should the nurse question?
The mother places the infant on her left side with a pillow supporting her back after feeding.
The mother covers the cast with a towel to prevent accidental soiling.
The mother uses the football hold to position the infant securely to one side.
The mother supports both the infant's head and cast when leaning her forward for burping.
The Correct Answer is C
Choice A rationale:
Placing the infant on her left side with a pillow supporting her back after feeding is appropriate as it prevents aspiration and reflux due to gravity.
Choice B rationale:
Covering the cast with a towel to prevent accidental soiling is a sensible action, ensuring the cast remains clean and dry.
Choice C rationale:
The mother using the football hold to position the infant securely to one side might hinder the cast's stability and could potentially cause discomfort or displacement.
Choice D rationale:
Supporting both the infant's head and cast when leaning her forward for burping is essential to maintain the cast's integrity and to prevent strain on the infant's body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Giving the patient a soft tissue is not the initial action to take when dealing with clear liquid drainage from the nose. Assessing the content of the drainage is more crucial for appropriate management.
Choice B rationale:
Checking the drainage for glucose content is essential because the presence of glucose indicates that the drainage is cerebrospinal fluid (CSF), which can occur with a skull fracture that involves the base of the skull.
Choice C rationale:
Obtaining a specimen of the drainage for culture and sensitivity is important, but it is not the initial action. Confirming the nature of the drainage takes precedence.
Choice D rationale:
Asking the father about nasal drainage before the injury is not as relevant as assessing the current drainage, which could be indicative of a CSF leak.
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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