A mother confides to the nurse that her live-in boyfriend knocked down her 2-year-old child because he was crying too much.
She begs the nurse not to tell anyone because her boyfriend has agreed to take anger management classes.
Which of the following actions should be taken by the nurse?
Arrange for counseling for the boyfriend at the earliest possible availability.
Encourage the mother to take the child and find alternate housing right away.
Report the incident to child protective services or other appropriate legal authority.
Abide by the mother's wishes because this information was provided in confidence.
The Correct Answer is C
Choice A rationale
Counseling for the boyfriend does not address the immediate safety risks to the child, who may remain vulnerable to further harm in the current environment.
Choice B rationale
While alternate housing might protect the child, it delays mandatory reporting, which is a legal obligation for healthcare providers in suspected abuse cases to ensure child welfare.
Choice C rationale
Reporting to child protective services is legally required and ensures the safety of the child while allowing investigation into the abuse for appropriate intervention and support.
Choice D rationale
Maintaining confidentiality is not applicable in cases of suspected child abuse, as healthcare providers are mandated reporters and must prioritize the child's safety over privacy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Primary prevention involves actions like immunizations and education to prevent diseases or issues before they occur. Drug screening is not aimed at preventing drug use but detecting it early.
Choice B rationale
Secondary prevention focuses on early detection and intervention to reduce the progression of disease or complications. Drug screening detects drug use early to prevent worsening outcomes, making this action a secondary prevention method.
Choice C rationale
Combining primary and secondary prevention involves overlapping strategies to prevent diseases and detect them early. Drug screening alone does not include primary preventive measures, so it cannot be classified as both.
Choice D rationale
Tertiary prevention is aimed at minimizing the impact of ongoing disease or injury, focusing on rehabilitation or management. Drug screening does not involve rehabilitating or managing drug-related complications.
Correct Answer is D
Explanation
Choice A rationale
White vaginal discharge is scientifically recognized as leukorrhea, a normal physiological change during pregnancy. It results from increased estrogen and cervical mucus production, serving to protect the vaginal environment.
Choice B rationale
Darkening of nipples and areolae is scientifically attributed to hormonal changes, specifically melanocyte-stimulating hormone, during pregnancy, preparing the breast for potential nursing functions post-birth.
Choice C rationale
Scientifically, rolling over is a developmental milestone typically achieved by six months. The statement aligns with age-specific motor skill development benchmarks based on neurological growth.
Choice D rationale
Not needing a doctor post-birth contradicts scientific guidelines. Neonates require early evaluation for congenital conditions, vaccinations, and monitoring of initial growth and development within days after birth.
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