An infant has undergone surgical repair of her myelomeningocele and is returned to the pediatric unit. Her mother tearfully says to the nurse, "I wish I could hold my baby.”. Which nursing action would be most appropriate?

Explore with the mother why she wants to hold the baby at this time.

Show the mother how to lightly rub the baby's back above the suture line.

Help the mother hold the baby without placing pressure on the suture line.

Reassure the mother that she will be able to hold her baby in four to five days.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Exploring why the mother wants to hold the baby is important, but it does not directly address her immediate desire to hold her baby. Delaying the action could lead to emotional distress for the mother.

Choice B rationale:

Showing the mother how to lightly rub the baby's back above the suture line might be appropriate, but it doesn't fulfill the mother's wish to hold her baby. It also doesn't fully consider the sensitivity of the surgical site.

Choice C rationale:

Helping the mother hold the baby without placing pressure on the suture line is the most appropriate action. It addresses the mother's emotional needs while also considering the infant's post-operative condition.

Choice D rationale:

Reassuring the mother that she will be able to hold her baby in four to five days does not provide immediate comfort and support for her emotional distress. It's important to address her needs in the present moment.

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Correct Answer is D

Explanation

Choice D rationale:

Monitoring the cardiac catheterization site for bleeding is the priority nursing intervention when a child feels nauseous and vomits after a cardiac catheterization. Bleeding from the catheterization site could lead to serious complications and requires immediate attention.

Choice A rationale:

Applying a cool cloth to the child's forehead can provide comfort, but it doesn't address the potential complication of bleeding from the catheterization site.

Choice B rationale:

Offering the child sips of orange juice is not appropriate if the child is nauseous and vomiting. Fluid intake should be monitored, but bleeding assessment takes priority.

Choice C rationale:

Applying pressure to the cardiac catheterization site is not the priority intervention. Monitoring for bleeding and assessing the site are more important.

A. Avoid setting limits or establishing disciplinary guidelines. B. Encourage the child to socialize with same-aged children. C. Avoid discussing sexuality until the child is an adult. D. Encourage delaying the child's entry into educational programs.

Correct Answer is B

Explanation

Choice A rationale:

Avoid setting limits or establishing disciplinary guidelines is not appropriate. Children with cognitive impairment require structure and consistent boundaries to ensure their safety and development.

Choice B rationale:

Encouraging the child to socialize with same-aged children is important for their social and emotional development. Interaction with peers fosters communication skills and helps them integrate into society.

Choice C rationale:

Avoid discussing sexuality until the child is an adult may lead to misinformation and confusion. Addressing sexuality in an age-appropriate manner is vital to help the child develop a healthy understanding of their body and relationships.

Choice D rationale:

Encouraging delaying the child's entry into educational programs hinders their cognitive and intellectual growth. Early intervention and tailored educational programs are crucial for children with cognitive impairment to reach their full potential.

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An infant has undergone surgical repair of her myelomeningocele and is returned to the pediatric unit. Her mother tearfully says to the nurse, "I wish I could hold my baby.”. Which nursing action would be most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a 9-year-old child feels nauseous and vomits after a cardiac catheterization, which is the priority nursing intervention?

Correct Answer is D

Explanation

What information should a nurse plan to give the parents of a child newly diagnosed with cognitive impairment (mental retardation)?

Correct Answer is B

Explanation

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