The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.

Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.

Each row must have one option selected.

Choice A rationale

This choice suggests assessing if the child can administer the insulin. While it's important for children with diabetes to learn self-care skills, a 10-year-old may not yet be ready to take on the responsibility of injecting insulin regularly. The child might still rely on parental or caregiver support for this task. Moreover, it does not address the immediate issue of the mother's fear of needles.

Choice B rationale

This choice focuses on assessing the mother's parenting skills. It is not directly related to solving the issue of insulin administration. The mother's fear of needles does not necessarily reflect her overall parenting skills. Assessing parenting skills would not provide a practical solution to the child's need for insulin administration.

Choice C rationale

Encouraging the mother to handle the needles could help overcome her fear, but it might not be effective in the short term. The mother might need time and professional help to deal with her fear of needles. This choice does not provide an immediate solution for the child's need for insulin injections.

Choice D rationale

Asking if the father can help with the injections is a practical and immediate solution. If the father is available and comfortable with handling needles, he can take on the responsibility of administering insulin to the child. This ensures that the child's medical needs are met while giving the mother time to overcome her fear of needles.

Choice A rationale

Non-nutritive sucking, such as with a pacifier, can be soothing and calming for infants. It helps in the development of oral motor skills and provides comfort during enteral feedings, ensuring that the infant’s need for sucking is met even when they are not feeding.

Choice B rationale

Sterile technique is essential for preventing infections during invasive procedures, but enteral feeding typically does not require such stringent measures. Clean technique is usually sufficient unless the infant has a compromised immune system or other specific medical conditions requiring sterile precautions.

Choice C rationale

While verifying tube placement is critical, it is often done using methods such as pH testing of gastric contents or external marking rather than routine x-rays. Overuse of x-rays exposes infants to unnecessary radiation. X-rays are used primarily when other methods are inconclusive.

Choice D rationale

Instituting physical therapy for a one-month-old infant would not be developmentally appropriate as their primary needs are centered around nutrition, comfort, and growth. Physical therapy is more relevant for older children with developmental or mobility issues rather than infants receiving enteral feedings. .