A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse?
“I try to respond to the baby quickly so she doesn't cry very long."
"I have several friends who come by to help out with the baby."
"I want to meet other parents to see if they are going through the same things."
“I think the baby should be sleeping through the night by now”
The Correct Answer is D
Choice A reason:
"I try to respond to the baby quickly so she doesn't cry very long." This statement is incorrect because it indicates the parent's sensitivity to the baby's needs and responsiveness to the baby's cues, which are positive signs of appropriate caregiving.
Choice B reason:
"I have several friends who come by to help out with the baby." This statement is incorrect because having a support system in the form of friends who help with the baby is a positive factor that can reduce stress and promote a healthy postpartum period.
Choice C reason:
"I want to meet other parents to see if they are going through the same things." This statement is incorrect because seeking social support and connecting with other parents can be beneficial in reducing feelings of isolation and stress during the postpartum period.
Choice D reason:
"I think the baby should be sleeping through the night by now is the correct statement "I think the baby should be sleeping through the night by now," as a manifestation of increased risk for child abuse. This statement may indicate unrealistic expectations or frustration from the parent regarding the baby's sleep patterns.
It is common for newborns to wake frequently during the night for feeding and care, and their sleep patterns can vary significantly in the early weeks and months of life. Unrealistic expectations or frustration about the baby's sleep habits can contribute to increased stress for the parent, which might increase the risk of child abuse or neglect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because after puncturing the skin and the vein, the nurse needs to advance the catheter into the vein with the finger hub to ensure proper placement and prevent complications such as infiltration or phlebitis.
Choice A is wrong because flushing the catheter with saline should be done after securing the catheter to the skin with a transparent dressing and attaching a primed piece of extension tubing to the catheter.
Choice B is wrong because retracting the stylet should be done after advancing the catheter into the vein and releasing the tourniquet from the client’s arm.
Choice C is wrong because releasing the tourniquet should be done after advancing the catheter into the vein and before retracting the stylet.
Correct Answer is A
Explanation
Choice A reason
The client is observed displaying a shuffling gait while walking in the hall is the correct answer. The nurse should recognize that observing a shuffling gait in a client who is taking antipsychotic medication is an adverse effect that must be reported to the healthcare provider. A shuffling gait is a movement disorder known as parkinsonism, which can be a side effect of some antipsychotic medications, particularly first-generation or typical antipsychotics.
Parkinsonism includes symptoms similar to Parkinson's disease, such as a shuffling walk, muscle stiffness, tremors, and difficulty with balance and coordination. It can occur as a result of blocking dopamine receptors in the brain, leading to an imbalance in dopamine levels.
Choice B reason:
The client mumbling quietly while alone is not correct because in the day room may be related to the symptoms of schizophrenia, and it does not indicate an adverse effect of the antipsychotic medication.
Choice C reason:
The client feeling light-headed when standing up quickly is not correct and it may be related to postural hypotension, which can be a side effect of some antipsychotic medications. While it should be monitored and reported if persistent or severe, it is not as urgent as reporting a shuffling gait.
Choice D reason:
The client stating that being in the sun hurts their eyes does not necessarily indicate an adverse effect of the antipsychotic medication. It may be related to other factors or unrelated to the medication.
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