A parent of a toddler asks the nurse the best way to handle the client's new temper tantrums at home.
What action should the nurse suggest?

Choice A rationale

Ignoring temper tantrums can sometimes be effective, but it may also escalate the behavior if the child feels their needs are not being met. From a psychological standpoint, the child is testing boundaries and seeking attention, and ignoring the behavior can be perceived as a lack of engagement, potentially intensifying the tantrum in an attempt to gain a reaction. This approach doesn't address the underlying developmental need for control and independence.

Choice B rationale

Distraction is a highly effective developmental strategy for toddlers. Toddlers have a short attention span and are easily redirected. By introducing a new, engaging activity, the nurse can shift the child's focus away from the source of frustration that triggered the tantrum. This technique prevents the tantrum from escalating and teaches the child to move on from a distressing situation without a power struggle, which is an important step in emotional regulation.

Choice C rationale

A toddler's cognitive development is not yet at a level where they can fully comprehend complex explanations about social norms or acceptable behavior. Their reasoning skills are still very primitive. Attempting to reason with a toddler during a tantrum is often futile and can even prolong the tantrum by giving the child attention for the negative behavior, thereby reinforcing it.

Choice D rationale

Placing a child in their room, or "time-out," is a discipline technique more appropriate for older children who can understand cause and effect. For a toddler, it can be perceived as abandonment or punishment without a clear connection to their behavior. This approach may not be effective and can cause fear or anxiety, failing to teach the child how to manage their emotions constructively.

Choice A rationale

Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. The primary concern is the potential for umbilical cord prolapse due to the gush of amniotic fluid, which can compromise fetal oxygenation. The fluid rate can be addressed after ensuring fetal well-being.

Choice B rationale

Providing a clean gown and linens is important for client comfort and hygiene but is not a priority over assessing fetal status. A change in linens can be done after the immediate safety of the fetus is confirmed, as a compromised fetal heart rate requires immediate intervention.

Choice C rationale

Assessing the fetal heart rate is the highest priority action after an amniotomy. The sudden release of amniotic fluid increases the risk of an umbilical cord prolapse, where the cord can be compressed, leading to a sudden decrease in fetal oxygenation and an emergent bradycardia. The normal fetal heart rate is 110-160 beats per minute.

Choice D rationale

Assisting the client with perineal hygiene is an important comfort measure and infection prevention strategy, but it is not the most critical and immediate action. The potential for a sudden, life-threatening change in fetal status due to cord prolapse takes precedence over hygiene.