Exhibits

Review H and P, and nurse's note.

Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.

Avoid mentioning anything about the mother to the child.

Develop a trusting relationship with the child.

Notify the mother that social services will be notified if she does not visit regularly.

Have the child sign a treatment contract stating he will participate in therapy.

Ask the mother to bring a familiar object from home.

Facilitate phone conversations between the child and his mother.

Answer and Explanation

Correct Answer : B,E,F

A.    Avoid mentioning anything about the mother to the child. Avoiding discussions about the mother may make the child feel more isolated and abandoned. Acknowledging his feelings and providing reassurance can help him cope with the separation.
B.   Develop a trusting relationship with the child. The child has experienced a long hospitalization and emotional distress from his mother’s absence. Establishing trust with the nurse and healthcare team can help him feel more secure and supported during this challenging time.
C.   Notify the mother that social services will be notified if she does not visit regularly. There is no indication of neglect or abandonment in this scenario. The mother had to leave due to a family illness, and threatening social services involvement may add unnecessary stress instead of fostering a supportive approach.
D.   Have the child sign a treatment contract stating he will participate in therapy. A 4-year-old is too young to understand or sign a treatment contract. Encouraging participation through play therapy, encouragement, and positive reinforcement is more developmentally appropriate.
E.   Ask the mother to bring a familiar object from home. A familiar blanket, stuffed animal, or toy can provide comfort and security for a hospitalized child experiencing separation anxiety. It helps maintain a sense of home and continuity while the mother is away.
F.    Facilitate phone conversations between the child and his mother. Regular phone or video calls can help maintain the child’s connection with his mother, reducing distress and providing reassurance that she has not abandoned him. This can help ease separation anxiety and improve emotional well-being.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Establish the frequency of headaches. While assessing headache history is important, an excruciating headache in a pregnant client with elevated blood pressure is a concerning sign of possible preeclampsia. Immediate evaluation for organ involvement, such as proteinuria, is more critical than determining headache patterns.
B. Ask about a history of delivering large babies. A history of macrosomia is more relevant for assessing gestational diabetes rather than hypertensive disorders. In this case, the priority is identifying potential complications of preeclampsia, which requires urine protein testing.
C. Examine the client for pedal edema. Although edema can be a sign of preeclampsia, it is also common in normal pregnancy. Generalized edema, particularly in the face and hands, may be more concerning, but the presence or absence of edema does not confirm or rule out preeclampsia.
D. Collect a urine sample to screen for protein. Proteinuria is a key diagnostic criterion for preeclampsia, along with hypertension and systemic symptoms such as severe headache. A urine dipstick or 24-hour urine collection helps determine if the client has preeclampsia, which requires urgent management to prevent complications like eclampsia or placental abruption.

A. Encourage breastfeeding every 2 to 3 hours. B. Administer antibiotics for 7 to 10 days. C. Give zidovudine 6 to 12 hours after birth. D. Delay the initial bath for 1 to 2 days.

Correct Answer is C

Explanation

A. Encourage breastfeeding every 2 to 3 hours. Breastfeeding is contraindicated in HIV-positive mothers in regions where safe formula feeding is available, as HIV can be transmitted through breast milk. Instead, formula feeding is recommended to prevent vertical transmission of the virus.
B. Administer antibiotics for 7 to 10 days. Routine antibiotic prophylaxis is not necessary for newborns born to HIV-positive mothers. Instead, the focus is on antiretroviral therapy (ART) to reduce the risk of HIV transmission. Antibiotics would only be indicated if there is a confirmed or suspected infection.
C. Give zidovudine 6 to 12 hours after birth. Newborns of HIV-positive mothers should receive zidovudine (AZT) as post-exposure prophylaxis within the first 6 to 12 hours after birth to reduce the risk of perinatal HIV transmission. The duration of therapy depends on the infant’s risk level, with high-risk infants receiving combination antiretroviral therapy.
D. Delay the initial bath for 1 to 2 days. The newborn should be bathed as soon as their temperature is stable to remove maternal blood and amniotic fluid, which could contain the virus. Early bathing reduces the risk of viral exposure through mucous membranes or breaks in the skin.

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Exhibits Review H and P, and nurse's note. Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?

Correct Answer is D

Explanation

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?

Correct Answer is C

Explanation

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?

A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse implement next?

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. Which response by the nurse will best explain the purpose for administering the ointment?

Exhibits The nurse is reviewing the prescription and planning the appropriate pain management. Complete the following sentence by choosing from the lists of options. For best pain management, the nurse should give... of acetaminophen every 4 hours as scheduled.

Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Exhibits

Review H and P, and nurse's note.

Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.