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: Having the child blow a cotton ball and have the parent catch it is not a good strategy to ensure the child's cooperation. This activity might distract the child from the assessment and make it difficult for the nurse to listen to the lung sounds.
Choice B reason: Allowing the child to use a stethoscope on a stuffed animal is a good strategy to ensure the child's cooperation. This activity helps the child to understand the purpose of the stethoscope and reduces the fear of the unfamiliar device. It also allows the nurse to observe the child's breathing pattern and chest movement.
Choice C reason: Offering the child bubbles before the stethoscope is placed is not a good strategy to ensure the child's cooperation. This activity might alter the child's breathing pattern and interfere with the accuracy of the assessment.
Choice D reason: Placing a toy in the child's hands while listening to the breath sounds is not a good strategy to ensure the child's cooperation. This activity might distract the child from the assessment and make it difficult for the nurse to listen to the lung sounds.
Correct Answer is C
Explanation
Choice A reason: Reassessing axillary temperature if it is higher than 99.7° F (37.6° C) is not a correct monitoring for early signs of an infection in the child. Axillary temperature is not the most accurate method of measuring body temperature, especially in children. It can be affected by factors such as clothing, sweating, and room temperature. Axillary temperature is usually lower than the core body temperature by about 1° F (0.6° C). Therefore, a child with an axillary temperature higher than 99.7° F (37.6° C) may already have a significant fever and should be evaluated by a health care provider.
Choice B reason: Verifying if the child has a fever by checking a rectal temperature is not a correct monitoring for early signs of an infection in the child. Rectal temperature is the most accurate method of measuring body temperature, but it is also the most invasive and uncomfortable. It can cause irritation, bleeding, or injury to the rectum, especially in children with low platelet counts or bleeding disorders. Rectal temperature is also not recommended for children with acute lymphoblastic leukemia, as it can increase the risk of introducing bacteria or fungi into the bloodstream.
Choice C reason: Notifying for a temporal temperature greater than 100° F (37.8° C) is a correct monitoring for early signs of an infection in the child. Temporal temperature is a noninvasive and convenient method of measuring body temperature, using an infrared scanner that detects the heat emitted by the temporal artery on the forehead. Temporal temperature is comparable to the core body temperature and can reflect changes in body temperature quickly. A child with acute lymphoblastic leukemia who has a temporal temperature greater than 100° F (37.8° C) may have an infection and should be reported to the health care provider immediately.
Choice D reason: Checking temperature twice a day with an aural thermometer is not a correct monitoring for early signs of an infection in the child. Aural temperature is a noninvasive and easy method of measuring body temperature, using an infrared sensor that detects the heat emitted by the tympanic membrane in the ear. However, aural temperature can be inaccurate or unreliable, as it can be affected by factors such as earwax, ear infections, ear canal shape, and ambient noise. A child with acute lymphoblastic leukemia who has a fever may not be detected by an aural thermometer, and may miss the opportunity for early intervention.
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