A nurse is caring for a client who had a vaginal birth 2 hours ago.
They are currently receiving Oxytocin, 20 Units in 1000 ml Lactated Ringer's solution infusing at 125 ml/hr. Which of the following findings indicates that the medication is effective?

Choice A rationale

This is not consistent with normal psychosocial development in this age group. An 18-month-old child is in the autonomy versus shame and doubt stage and typically exhibits separation anxiety, crying when parents leave. Being quiet suggests a lack of a strong attachment bond or a regression in developmental milestones. This behavior would warrant further assessment.

Choice B rationale

This behavior is a classic manifestation of the autonomy versus shame and doubt stage of Erikson's theory, which occurs between 18 months and 3 years. The child is asserting their independence and developing a sense of self-control and free will. Stomping and saying "no" are typical ways for toddlers to express their burgeoning autonomy.

Choice C rationale

Crying when the mother leaves is a normal developmental milestone known as separation anxiety. This indicates that the child has formed a secure attachment bond with their primary caregiver. It is a healthy sign of object permanence and a key feature of the trust vs. mistrust stage, which continues to influence later stages like autonomy.

Choice D rationale

This behavior is a red flag for abnormal development. At 18 months, children should be actively interacting with their parents and other caregivers. A lack of interaction could indicate developmental delays, sensory processing issues, or potential signs of a social communication disorder that requires further investigation by a healthcare professional.

Choice E rationale

Responding when called by name is a crucial developmental milestone in language and social development. This demonstrates that the child is able to attend to stimuli, has an understanding of their own identity, and is capable of receptive language skills, which are all vital components of healthy cognitive development in the toddler stage.

Choice F rationale

This indicates the child is developing a sense of self-control and competence, which is the hallmark of the autonomy versus shame and doubt stage. Successfully completing a task like toilet training gives the toddler a sense of accomplishment and independence. The smile is a positive emotional response to this newfound sense of control over their body.

Choice A rationale

While administering analgesics is a crucial step in managing a vaso-occlusive crisis due to severe pain, it is not the first intervention. The client's report of a severe headache with blurry vision, particularly in the context of sickle cell disease, is a sentinel symptom. These neurological signs can indicate a central nervous system complication, such as a stroke, which requires immediate neurological assessment before any other interventions.

Choice B rationale

In a vaso-occlusive crisis, a severe headache and blurry vision are neurological red flags. These symptoms suggest potential cerebral hypoxia or infarction, which could be a prelude to a stroke. Assessing the client's neurological status is the first priority to establish a baseline and determine the extent of the neurological deficit. This rapid assessment guides subsequent life-saving interventions.

Choice C rationale

Increasing intravenous fluids is a standard component of vaso-occlusive crisis management to promote hemodilution and improve blood flow. However, it is not the first action in this specific scenario. The client's presenting symptoms of headache and blurry vision point to a potential neurological emergency that requires immediate assessment to rule out or confirm a stroke, which takes precedence over general fluid management.

Choice D rationale

Administering oxygen is beneficial in a vaso-occlusive crisis to address tissue hypoxia. However, it is not the immediate first action given the client's specific neurological symptoms. Oxygen saturation is typically maintained above 95% in these patients. The priority is to assess the client's neurological status to rapidly identify a potentially life-threatening stroke, which dictates the immediate course of action.