The mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?
Position the infant on the stomach occasionally when awake and active.
Turn the infant on the left side braced against the crib when sleeping.
Place a small pillow under the infant's head while lying on the back.
Prop the infant in a sitting position with a cushion when not sleeping.
The Correct Answer is A
Choice A reason: Positioning the infant on the stomach occasionally when awake and active is the best response that the nurse can give to the mother. This is because it can help prevent and correct the flat head syndrome, also known as plagiocephaly, by taking pressure off the back of the head and allowing the skull to reshape naturally. It can also promote the infant's motor development and strengthen the neck and shoulder muscles. However, the nurse should also remind the mother to always place the infant on the back when sleeping, as this is the safest position to reduce the risk of sudden infant death syndrome (SIDS) .
Choice B reason: Turning the infant on the left side braced against the crib when sleeping is not a good response that the nurse can give to the mother. This is because it can increase the risk of SIDS, as the infant may roll over to the stomach or suffocate from the bedding or the crib. It can also worsen the flat head syndrome by creating another flat spot on the left side of the head.
Choice C reason: Placing a small pillow under the infant's head while lying on the back is not a good response that the nurse can give to the mother. This is because it can increase the risk of SIDS, as the pillow may cover the infant's face or cause the infant to overheat. It can also interfere with the natural reshaping of the skull and cause neck strain.
Choice D reason: Propping the infant in a sitting position with a cushion when not sleeping is not a good response that the nurse can give to the mother. This is because it can put too much pressure on the spine and the pelvis, which are still developing in the infant. It can also limit the infant's movement and exploration, which are important for learning and development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat heart failure in infants. It lowers blood pressure and reduces the workload of the heart. Enalapril is not contraindicated in this scenario and does not need to be withheld.
Choice B reason: Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias in infants. It increases the contractility of the heart and slows down the heart rate. Digoxin has a narrow therapeutic range and can cause toxicity if the dose is too high or the infant is dehydrated. Digoxin should be withheld if the infant's apical pulse is less than 90 beats/minute, which is the case in this scenario. The nurse should notify the health care provider and monitor the infant for signs of digoxin toxicity, such as nausea, vomiting, bradycardia, and visual disturbances.
Choice C reason: Hydralazine is a vasodilator that is used to treat hypertension and heart failure in infants. It lowers blood pressure and reduces the afterload of the heart. Hydralazine is not contraindicated in this scenario and does not need to be withheld.
Choice D reason: Furosemide is a loop diuretic that is used to treat fluid overload and edema in infants with heart failure. It lowers blood pressure and reduces the preload of the heart. Furosemide is not contraindicated in this scenario and does not need to be withheld
Correct Answer is B
Explanation
Choice A reason: Enabling limited time for cell phone use is not the best intervention that the nurse can implement to support the client's psychosocial needs. While cell phone use can help the client stay connected with their peers and social media, it can also be a source of distraction and stress. The nurse should encourage the client to balance their cell phone use with other activities that promote their well-being.
Choice B reason: Providing an activity room to spend time with other adolescents is the best intervention that the nurse can implement to support the client's psychosocial needs. This intervention can help the client cope with the anxiety and isolation that may result from their condition and hospitalization. It can also provide an opportunity for the client to interact with other adolescents who have similar experiences and challenges, and to engage in fun and meaningful activities that enhance their self-esteem and mood.
Choice C reason: Delivering 3 meals and snacks each day upon request is not the best intervention that the nurse can implement to support the client's psychosocial needs. While it is important to maintain the client's nutrition and hydration, it is not enough to address their emotional and social needs. The nurse should also encourage the client to eat with other adolescents or family members when possible, and to express their preferences and concerns about their food.
Choice D reason: Allowing family and friends to be present during assessments is not the best intervention that the nurse can implement to support the client's psychosocial needs. While it is important to involve the client's family and friends in their care, it is not necessary to have them present during every assessment. The nurse should respect the client's privacy and autonomy, and ask for their consent before allowing others to observe or participate in their assessments. The nurse should also provide the client with opportunities to talk to their family and friends in a comfortable and confidential setting.
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