A 6-year-old child with autism spectrum disorder (ASD) is hospitalized for a respiratory infection.
The nurse notices the child flapping his hands and rocking in the corner during assessment. What is the best nursing action?
Restrain the child for safety.
Allow self-soothing behavior and ensure a low-stimulus environment.
Redirect the child immediately to stop the behavior.
Engage in verbal interaction to distract the child.
The Correct Answer is B
Choice A rationale
Restraining a child with autism can exacerbate distress and lead to further agitation due to sensory overload and a feeling of loss of control. Physical restraint can activate the sympathetic nervous system, increasing heart rate and cortisol levels, which can traumatize the child and hinder therapeutic rapport, contravening principles of trauma-informed care.
Choice B rationale
Hand flapping and rocking are common self-stimulatory behaviors, or "stimming," in children with autism, serving to regulate sensory input and manage anxiety. Allowing these behaviors in a low-stimulus environment supports emotional regulation by reducing external stressors and promoting a sense of security, which is crucial for individuals with sensory processing differences.
Choice C rationale
Immediately redirecting or attempting to stop self-stimulatory behaviors can be counterproductive for a child with autism. These behaviors often serve a vital self-regulatory function; interrupting them without providing an alternative coping mechanism can increase anxiety, frustration, and escalate behavioral challenges, disrupting their internal equilibrium.
Choice D rationale
Engaging in verbal interaction to distract a child with autism during self-soothing can disrupt their regulatory process. Children with ASD often have difficulties with social communication and may find unexpected verbal input overwhelming, potentially increasing sensory overload and agitation, rather than providing effective distraction or comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Lochia rubra, characterized by bright red discharge, typically lasts for the first 3-5 days postpartum. Its presence at 5 weeks postpartum would be abnormal and could indicate a complication such as retained placental fragments or infection, necessitating further medical evaluation due to prolonged uterine bleeding.
Choice B rationale
Lochia serosa, a pinkish-brown discharge, typically follows lochia rubra and can persist for about 2 to 3 weeks postpartum. While some individual variation exists, its presence up to 6 weeks postpartum as the predominant discharge type is less common and might suggest a slower than average uterine involution.
Choice C rationale
Complete cessation of lochia by 5 weeks postpartum is not typical for most individuals. The puerperium, or postpartum period, involves significant uterine involution and discharge. While the volume decreases, some form of lochia, usually alba, is still physiologically expected as the uterus continues to heal and shed decidual tissue.
Choice D rationale
Lochia alba, a yellowish-white discharge, is the final stage of lochia and typically begins around 2 to 6 weeks postpartum, continuing for up to 6 weeks or even longer in some individuals. This discharge consists of leukocytes, decidual cells, mucus, and bacteria, signifying the continued, normal healing and involution of the uterus.
Correct Answer is A
Explanation
Choice A rationale
Rho(D) immune globulin, also known as RhoGAM, is an immunoglobulin product administered to Rh-negative individuals to prevent isoimmunization. It works by binding to and neutralizing any fetal Rh-positive red blood cells that may enter the maternal circulation, thereby preventing the maternal immune system from recognizing these cells and forming anti-Rh antibodies.
Choice B rationale
This statement is incorrect. Rho(D) immune globulin does not destroy pre-formed Rh antibodies in a woman. Its mechanism of action is prophylactic, preventing the initial sensitization and antibody formation, rather than treating existing antibodies. Once antibodies are formed, RhoGAM is ineffective.
Choice C rationale
This statement is incorrect. Rho(D) immune globulin is administered to the Rh-negative mother, not the Rh-positive newborn. The purpose is to protect future Rh-positive fetuses from maternal Rh antibody attack, as maternal antibodies can cross the placenta and cause hemolytic disease of the newborn.
Choice D rationale
This statement is incorrect. Rho(D) immune globulin is administered to the Rh-negative mother to prevent her immune system from forming antibodies. It does not directly act on the newborn or prevent antibody formation within the newborn. The focus is on maternal sensitization.
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