A client who is a primigravida tells the practical nurse (PN), "My baby seems to be sleeping, but look at the funny movements he is making." The PN notices that the infant is making hand-to-mouth movements, smacking his lips, and turning his head. Which is the best response for the PN to make?
These movements indicate that the infant is hungry.
Allow the infant to sleep. He is probably only dreaming.
Check to see if he needs his diaper changed.
The infant may be uncomfortable. Place him on his side.
The Correct Answer is A
A. These movements indicate that the infant is hungry: Hand-to-mouth movements, lip smacking, and turning the head are early hunger cues in infants. Recognizing and responding to these cues promotes effective feeding and helps establish breastfeeding or bottle-feeding routines.
B. Allow the infant to sleep. He is probably only dreaming: Infants may make movements while sleeping, but the behaviors described are classic early hunger cues, not sleep-related activity. Ignoring these signs may delay feeding and increase infant distress.
C. Check to see if he needs his diaper changed: While a wet or soiled diaper can cause discomfort, the specific movements of hand-to-mouth and lip smacking are more indicative of hunger than diaper needs.
D. The infant may be uncomfortable. Place him on his side: Positioning the infant on the side may help with reflux or sleep, but it does not address the primary reason for the observed behaviors, which are hunger cues requiring feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Provide gentle and meticulous mouth care: Stomatitis causes painful inflammation and ulceration of the oral mucosa. Gentle, thorough oral care reduces the risk of infection, promotes healing, and helps maintain oral hygiene, making this the most important instruction for the UAP.
B. Keep the room environment free of unpleasant odors: Minimizing odors can help with nausea, but it does not directly address stomatitis care. This is a supportive measure, not a primary intervention.
C. Assist the client with feeding at meal times: Assistance with feeding is helpful for comfort and nutrition, but it does not directly manage the oral lesions or reduce infection risk.
D. Gather supplies for protective environment precautions: Protective environment precautions are primarily used for clients with severe immunosuppression. While important in some chemotherapy settings, the key intervention for stomatitis is proper oral care.
Correct Answer is B
Explanation
A. "I don't have any use for those who say this disease is going to win": This statement reflects anger or resistance, which is common in earlier stages of grief and adjustment, rather than acceptance of prognosis.
B. "I've found the support I need from my faith and family": Seeking and acknowledging support demonstrates that the client has processed emotions, adapted to the diagnosis, and reached a level of acceptance, allowing for coping and meaningful engagement with life.
C. "I think I've had this disease for a long time, but the doctor did not find it": This statement reflects confusion or disbelief, indicating the client is still processing the diagnosis rather than accepting it.
D. "I understand that this is a disease that occurs mostly in older men": While factual understanding shows knowledge about the disease, it does not necessarily reflect personal acceptance of prognosis or emotional adjustment.
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