A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries.
My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?

Choice A rationale

Reaction formation involves behaving in a way that is the opposite of one's true feelings. The client's statement focuses on delaying health concerns rather than expressing the opposite of their anxiety about their diagnosis.

Choice B rationale

Splitting is a defense mechanism where individuals view themselves or others as all good or all bad. The client's statement does not demonstrate this polarized thinking; instead, it shows a postponement of addressing their health.

Choice C rationale

Projection involves attributing one's own unacceptable thoughts or feelings onto another person. The client is not attributing their feelings about their cancer diagnosis to someone else; they are simply putting off thinking about it.

Choice D rationale

Suppression is a conscious or semiconscious effort to avoid thinking about disturbing thoughts or feelings. The client is consciously stating their intention to not think about their cancer diagnosis until after their son's wedding, indicating a deliberate avoidance of the topic.

Choice A rationale

Interviewing the child about suspected abuse with a parent present could compromise the investigation and potentially endanger the child further. The parent, if the abuser, might intimidate or coach the child, preventing the disclosure of crucial information. A private, safe environment is necessary for the child to speak freely.

Choice B rationale

Completing an incident report for risk management is an important internal administrative step for the healthcare facility. However, it does not fulfill the legal and ethical obligation to report suspected child abuse to the appropriate external authorities who can initiate an investigation and ensure the child's safety.

Choice C rationale

Informing the parents that the findings must be reported to authorities might alert a potential abuser and could lead to further harm or the destruction of evidence. The priority is the child's safety, and direct reporting to the appropriate agency is the necessary first step.

Choice D rationale

Reporting suspected child abuse to the appropriate child protective services agency is the mandated legal and ethical responsibility of healthcare professionals. A perforated eardrum in a school-age child, especially if the explanation is inconsistent with the injury, raises suspicion of non-accidental trauma and requires immediate reporting to ensure the child's safety and well-being.