A nurse is caring for an infant who sustained critical injuries in a motor vehicle accident and is not expected to survive. Which of the following interventions should the nurse implement to support the infant's parents in anticipatory grieving?
Cover the equipment used in the infant's care prior to the parents' first visit.
Reduce the parents' distress by limiting the duration of their visit.
Avoid leaving the parents alone with the infant during their visit.
Involve the parents in the infant's caregiving activities during their visit.
The Correct Answer is D
A. Cover the equipment used in the infant's care prior to the parents' first visit: While this might reduce visual distress, it does not directly support the grieving process or involve the parents in meaningful interactions.
B. Reduce the parents' distress by limiting the duration of their visit: Limiting visit time may increase distress by reducing opportunities for the parents to process emotions.
C. Avoid leaving the parents alone with the infant during their visit: Parents may value privacy to express their feelings and bond with the infant without outside observation.
D. Involve the parents in the infant's caregiving activities during their visit. Involving parents in caregiving helps them feel connected to their child and provides meaningful time to bond, which supports healthy grieving.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","G","H","I","J"]
Explanation
A. Intake and output: The infant has not fed in 8 hours and has only had 1 wet diaper during this time, which is concerning for dehydration or inadequate intake. The decreased output requires immediate follow-up to prevent further dehydration and assess fluid needs.
B. Heart rate: The heart rate of 180/min is elevated for an infant, potentially indicating dehydration, fever, or respiratory distress. Tachycardia can also signify compensation for hypoxia.
C. Respiratory rate: A respiratory rate of 60/min is elevated for an infant and indicates respiratory distress, compounded by retractions and diminished lung sounds in the right lobes.
D. Bowel sounds: Active bowel sounds in all four quadrants are a normal finding and do not indicate an acute issue.
E. Mucous membranes: While dry mucous membranes confirm dehydration, they are not the highest priority compared to respiratory distress or oxygen saturation.
F. Weight: Weight loss from 9 lb to 8 lb 8 oz is concerning for chronic dehydration or inadequate nutrition, but it does not require immediate action compared to acute respiratory and oxygenation issues.
G. Retractions: Moderate substernal and intercostal retractions are indicative of respiratory distress. This requires immediate follow-up to assess the severity of the distress and initiate appropriate interventions, such as supplemental oxygen or further evaluation.
H. Lung sounds: Diminished lung sounds in the right lobes and occasional coarse crackles are concerning for a respiratory infection or condition such as pneumonia or bronchiolitis. Immediate follow-up is required to assess the cause and severity of the respiratory findings.
I. Temperature: The infant has a fever, which is concerning, especially with poor feeding and lethargy. Fever in an infant can indicate a serious infection (e.g., sepsis, urinary tract infection, or pneumonia) that requires immediate medical attention and further investigation.
J. Oxygen saturation: An oxygen saturation of 92% is low for an infant, indicating hypoxia, likely due to respiratory compromise. Immediate intervention (e.g., oxygen therapy) is necessary to prevent further deterioration.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
1. Failure to thrive: The infant has poor weight gain despite being hungry after vomiting. Projectile vomiting, as described, often leads to insufficient caloric intake, putting the infant at risk for failure to thrive.
2. Dehydration: Repeated vomiting results in fluid loss, putting the infant at high risk of dehydration, which is common in conditions like pyloric stenosis, suspected here due to the symptoms and palpable abdominal mass.
3. Intussusception typically presents with intermittent, severe abdominal pain, "currant jelly" stools, and sometimes a sausage-shaped mass, which are not noted in this scenario.
4. Meckel diverticulum can cause painless rectal bleeding or obstruction symptoms but is not associated with projectile vomiting or a palpable mass.
5. Hirschsprung disease presents with failure to pass meconium, abdominal distension, and chronic constipation rather than the projectile vomiting seen here.
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