A nurse reports an incident of suspected child abuse.

One of the parents of the child becomes upset and demands to know the reason for the nurse's action.

Which of the following responses by the nurse is appropriate?

Choice A rationale

Trust versus mistrust is the first stage of Erikson's psychosocial development, occurring from birth to about 18 months. Successful completion results in confidence and security, while failure leads to anxiety and mistrust of the world. This stage is not relevant to the adolescent's struggle for social acceptance and self-image among peers.

Choice B rationale

Autonomy versus shame and doubt is Erikson's second stage, typically seen in the toddler period (18 months to 3 years). This stage focuses on gaining independence in basic self-care activities, such as toilet training and walking. The conflict is centered on self-control and the ability to act on one's own, which differs from the adolescent need for peer identity.

Choice C rationale

Identity versus role confusion is Erikson's fifth stage, which is the central developmental task of adolescence. During this stage, the teenager is trying to figure out "who they are" and where they fit in the world, often through experimentation with different roles, values, and peer groups. The desire to dress like others reflects the search for a sense of belonging and a unified self-concept.

Choice D rationale

Initiative versus inferiority is Erikson's fourth stage, usually seen in school-age children (6 to 12 years). This stage focuses on developing a sense of competence and pride in schoolwork and other activities, comparing their abilities with peers. While peer interaction is important, the core conflict is about competence and achievement, not the broader self-identity search seen in the teenage years.

Choice A rationale

Digoxin is a cardiac glycoside that slows and strengthens the heart rate and is commonly used in infants with heart failure. For an infant, the normal apical pulse rate typically ranges from 100 to 160 beats per minute. A rate of 80 beats per minute is significantly below the acceptable lower limit, indicating potential digoxin toxicity or an existing underlying bradycardia, requiring the nurse to hold the dose and notify the physician immediately to prevent serious adverse effects.

Choice B rationale

A heart rate of 140 beats per minute is within the normal physiological range for an infant, which is generally 100 to 160 beats per minute. This rate is considered acceptable and does not warrant holding the prescribed dose of digoxin, assuming other parameters and clinical signs of toxicity are absent. Digoxin aims to improve cardiac contractility and may slightly slow the rate but 140 is a safe rate.

Choice C rationale

An apical pulse rate of 100 beats per minute sits at the lower boundary of the normal range for an infant, which spans from 100 to 160 beats per minute. While close to the cutoff, it is still technically acceptable for administering digoxin. The nurse would monitor closely, but the dose would generally not be withheld unless the rate was less than 90 or 100, depending on the facility policy.

Choice D rationale

A heart rate of 120 beats per minute is well within the expected and safe normal range for an infant, which typically extends from 100 to 160 beats per minute. This rate is adequate and does not suggest bradycardia or pose any immediate concern regarding digoxin administration. The dose should be given as scheduled, and continued monitoring should take place.