A nurse reviews the history and physical and the nurse’s note for a child. Which action is most appropriate for the nurse caring for this child?
Develop a trusting relationship with the child.
Avoid mentioning anything about the mother to the child.
Notify the mother that social services will be notified if she does not visit regularly.
Ask the mother to bring a familiar object from home.
Have the child sign a treatment contract stating he will participate in therapy.
Facilitate phone conversations between the child and his mother.
Correct Answer : A,D,F
Choice A rationale
A trusting relationship is foundational for therapeutic interventions with a child. By building rapport, the nurse creates a safe and secure environment. This allows the child to feel comfortable expressing feelings, anxieties, and fears associated with their health condition and hospitalization. A strong therapeutic alliance enhances cooperation, reduces resistance to care, and improves the overall effectiveness of the treatment plan. Trust is a cornerstone of pediatric nursing.
Choice B rationale
Avoiding mention of the mother may create a sense of abandonment or unimportance for the child, potentially increasing anxiety and emotional distress. Children, even when separated from a parent, need to feel that the parent is still a significant part of their life. This approach can also hinder the child's ability to process their feelings about the separation and can impede effective communication with the nurse. It is not therapeutic.
Choice C rationale
Notifying a parent that social services will be contacted if they do not visit regularly is an inappropriate action for a nurse. This constitutes a threat and is not within the scope of a nurse's role. Such a statement is coercive and unprofessional, potentially damaging the relationship with the family. The nurse's role is to advocate for the child and support the family, not to impose punitive measures. This action is counterproductive to establishing a therapeutic partnership.
Choice D rationale
Bringing a familiar object, such as a favorite toy or blanket, from home provides a transitional object for the child. This object offers a sense of security and continuity with their home environment, which can significantly reduce the stress and anxiety associated with hospitalization. It helps the child feel more in control and comforted in an unfamiliar setting, promoting emotional well-being and making the hospital stay less frightening.
Choice E rationale
A child, especially one who is emotionally distressed or of a young age, lacks the cognitive maturity and legal capacity to enter into a binding treatment contract. This is an inappropriate and unrealistic expectation. It can increase the child's anxiety and lead to feelings of failure if they are unable to comply. The nurse's role is to guide and support the child, not to enforce a formal contract. Informed consent is provided by the parent or legal guardian.
Choice F rationale
Facilitating phone conversations between the child and their mother helps maintain the parent-child bond despite physical separation. Regular communication provides reassurance to the child that they have not been forgotten and helps reduce feelings of abandonment and loneliness. This connection is vital for emotional security and supports the child's coping mechanisms during a stressful hospital stay, promoting a sense of normalcy and continuity of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Introducing solid foods at one year of age is too late and may hinder the infant's nutritional development. The American Academy of Pediatrics recommends starting between 4 to 6 months of age when the infant displays readiness cues like head control and interest in food. Waiting too long can lead to nutrient deficiencies, particularly iron, as maternal stores begin to deplete.
Choice B rationale
Introducing new foods one at a time is crucial for identifying potential food allergies or sensitivities. Simultaneous introduction of fruits and vegetables would make it difficult to pinpoint the specific food causing an allergic reaction. This staggered approach, over several days, allows the immune system to acclimate to each new food.
Choice C rationale
Feeding solids from a bottle can lead to overfeeding, as the infant may not be able to regulate intake appropriately. It also bypasses the critical developmental stage of learning to swallow thicker textures and use a spoon. The infant needs to develop oral motor skills and coordination for successful and safe solid food consumption.
Choice D rationale
Introducing new foods one at a time, with a waiting period of 4 to 7 days, is the recommended practice. This method allows the caregiver to easily identify any adverse reactions, such as a rash, diarrhea, or vomiting, associated with a specific food. It's a key strategy for the early detection and management of food allergies.
Correct Answer is D
Explanation
Choice A rationale
Rubbing the infant's back provides tactile stimulation, which can encourage deeper breaths and a more vigorous cry, aiding in the transition to extrauterine life. While this is a valid intervention for a sluggish infant, it may not be necessary if the respiratory rate is already within the normal range of 30-60 breaths/minute. Cyanosis of the hands and feet (acrocyanosis) is a common, benign finding.
Choice B rationale
Assessing bowel sounds is part of a comprehensive newborn assessment but is not a priority in a situation where the nurse is evaluating respiratory status and color. Bowel sounds provide information about gastrointestinal function and are not directly related to the infant's oxygenation or transition to extrauterine life. This assessment would be performed after ensuring adequate cardiorespiratory function.
Choice C rationale
Intubation is an invasive procedure reserved for infants who are not breathing or have severe respiratory distress, such as a respiratory rate below 30 breaths/minute or persistent central cyanosis. A respiratory rate of 40 breaths/minute is within the normal range for a newborn, indicating adequate respiratory effort. Therefore, intubation is not warranted at this time.
Choice D rationale
Acrocyanosis, or cyanosis of the hands and feet, is a normal physiological finding in the first 24 hours of life due to immature peripheral circulation. The infant's respiratory rate of 40 breaths/minute is within the expected range for a newborn (30-60 breaths/minute). The combination of a normal respiratory rate and benign acrocyanosis indicates the infant is transitioning normally, and continued monitoring is the appropriate action.
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