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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Return of the uterus to prepregnancy size. While oxytocin helps contract the uterus, the complete process of involution (uterus returning to prepregnancy size) takes about 6 weeks postpartum. Oxytocin primarily aids in immediate postpartum contraction to reduce bleeding.
B. Expulsion of the placenta. Oxytocin is typically administered after placental delivery to prevent postpartum hemorrhage. If the placenta does not expel naturally, manual removal may be needed. Oxytocin is more effective in promoting uterine tone rather than actively expelling the placenta.
C. Activation of the let-down reflex. Oxytocin plays a role in milk ejection during breastfeeding, but when administered intravenously postpartum, its primary purpose is to stimulate uterine contractions. Natural oxytocin release from breastfeeding supports the let-down reflex, but this is not the main goal of IV oxytocin administration.
D. Stimulation of uterine contractions. IV oxytocin is given postpartum to promote uterine contractions, which help reduce postpartum bleeding by compressing uterine blood vessels. This action is critical in preventing postpartum hemorrhage and ensuring uterine firmness.
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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