A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?
"Have you tried holding your infant skin-to-skin?"
"is your infant able to latch on during breastfeeding?"
"What is your infant's level of activity?"
"Have you considered joining a parents' support group?"
The Correct Answer is B
A) "Have you tried holding your infant skin-to-skin?":
While skin-to-skin contact can be beneficial for infant bonding and comfort, the priority for a postoperative infant following a cleft palate repair is to ensure adequate feeding. While skin-to-skin contact can promote bonding and provide comfort, it does not directly address the infant's ability to latch on during breastfeeding, which is crucial for nutritional intake and healing postoperatively.
B) "Is your infant able to latch on during breastfeeding?":
This question addresses the priority concern for the nurse, which is the infant's ability to effectively latch on during breastfeeding. Adequate latch is essential for proper nutrition and hydration, especially for an infant recovering from a cleft palate repair surgery. The nurse needs to assess whether the infant can latch on properly to ensure adequate feeding and support optimal healing.
C) "What is your infant's level of activity?":
While assessing the infant's level of activity is important for overall health and well-being, it is not the priority question in this scenario. The nurse's primary focus should be on assessing the infant's feeding ability and ensuring adequate nutritional intake postoperatively.
D) "Have you considered joining a parents' support group?":
Joining a parents' support group can be valuable for emotional support and sharing experiences, but it is not the priority question in this situation. The immediate concern is ensuring the infant's nutritional needs are being met, particularly in the context of breastfeeding challenges following cleft palate repair surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) A nurse tells a client's health care surrogate that the client might require restraints if diversion activities are ineffective:
This scenario does not represent slander. While discussing the possibility of using restraints with a client's health care surrogate involves sensitive communication, it does not constitute slander. The nurse is providing information about potential interventions based on the client's needs and safety concerns, which is a part of the nursing role.
B) A nurse documents that a client was shouting and directly quotes the client's words:
This scenario involves accurate documentation of a client's behavior and does not constitute slander. Documenting a client's actions, such as shouting, with direct quotes from the client's words is essential for providing an accurate record of events and communication during the client's care.
C) A client overhears assistive personnel make a false statement about the assigned nurse and requests a different nurse:
This scenario represents slander. Slander involves making false statements that harm someone's reputation, and in this case, the assistive personnel's false statement about the assigned nurse could damage the nurse's professional reputation. The client's request for a different nurse indicates the potential negative impact of the false statement on the nurse's relationship with the client.
D) A staff member reports to the unit supervisor during a private meeting that a coworker is possibly impaired:
This scenario involves reporting a concern about a coworker's potential impairment, which is not an example of slander. Reporting concerns about impairment is a critical aspect of ensuring patient safety and maintaining professional standards in healthcare settings. However, such reports should be handled confidentially and with appropriate discretion.
Correct Answer is A
Explanation
A) The client rates her pain at a 3 on a 0 to 10 pain rating scale:
In the SBAR communication technique, "A" stands for "Assessment." This portion of the report should include concise and pertinent information about the client's current condition or status. The client's pain level, rated on a standardized pain scale, is a crucial assessment parameter that provides immediate insight into the client's comfort and potential need for intervention or further assessment.
B) The client has type 2 diabetes mellitus:
While the client's medical history of type 2 diabetes mellitus is important information, it is more relevant to the client's overall health status and background. In the SBAR framework, this information would typically be included in the "B" (Background) portion of the report, which focuses on contextual information such as medical history, current diagnoses, and relevant background information about the client.
C) The client is 2 hours postoperative following a cholecystectomy:
The fact that the client is 2 hours postoperative following a cholecystectomy is significant information regarding the client's recent surgical procedure and immediate postoperative status. However, this information falls under the "B" (Background) portion of the SBAR report, which includes details about the client's recent events, procedures, or treatments.
D) The client should wear compression stockings:
Information about the client's prescribed interventions or treatments, such as wearing compression stockings, is essential for continuity of care and ensuring that appropriate interventions are continued. However, this information is typically included in the "R" (Recommendation) portion of the SBAR report, where the nurse may provide recommendations for ongoing care or interventions based on the client's current condition and needs.
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