The nurse is caring for a 37-weeks gestation infant born to a parent with hepatitis B. Which intervention will the nurse include in the plan of care?

Choice A reason: Scheduling a full neurological evaluation is the appropriate action in this scenario. The sudden regression in the child's ability to walk is a significant concern that requires immediate investigation to rule out any underlying neurological or medical conditions. A full neurological evaluation will help identify any issues such as developmental delays, neuromuscular disorders, or other conditions that may be affecting the child's motor skills. Prompt evaluation and diagnosis are crucial for early intervention and appropriate management.

Choice B reason: Recommending follow-up in 30 days after documenting the regression is not an ideal approach in this situation. Given the severity of the regression in the child's walking ability, waiting for 30 days without further investigation could delay critical diagnosis and treatment. Immediate assessment is necessary to address potential underlying issues and provide timely intervention.

Choice C reason: Questioning the parents about changes in the child's activity schedule is important but should not be the sole action taken. While gathering information about the child's activities and environment can provide valuable context, it does not replace the need for a thorough medical evaluation. The primary concern here is the sudden regression in motor skills, which warrants a full neurological assessment.

Choice D reason: Documenting the findings and scheduling an 18-month well-visit is also not sufficient. While it is essential to document the observed regression, delaying further action until the next routine check-up could result in missed opportunities for early diagnosis and intervention. The priority should be to conduct a neurological evaluation to understand the cause of the regression and take appropriate steps to address it.

Choice A reason: This statement suggests a rigid schedule for feeding, which may not always align with an infant's natural hunger cues. While some babies may follow a regular feeding pattern, it's essential to prioritize the baby's hunger cues over a strict schedule. Feeding on demand, when the baby shows signs of hunger, is generally recommended to ensure they receive adequate nutrition and comfort.

Choice B reason: Advising not to wake a sleeping baby for feeding is not accurate for all situations. Newborns, especially in the first few weeks, may need to be woken for feeding if they are not gaining weight adequately or if they have medical conditions that require regular feeding. It is important to balance letting the baby sleep and ensuring they get enough nutrition, particularly in the early stages.

Choice C reason: Feeding the baby when they start smacking their lips or sucking on their hands demonstrates an understanding of responding to hunger cues. These behaviours are early signs of hunger, and feeding the baby at this stage can prevent them from becoming overly hungry and fussy. This approach aligns with best practices for feeding on demand, promoting healthy growth and development.

Choice D reason: This statement reflects a misunderstanding of infant care. Crying is a late sign of hunger, and it is important to respond to early hunger cues to prevent distress. The idea that responding too soon to a baby's needs will spoil them is a myth. Timely and responsive care fosters a sense of security and trust in the caregiver-infant relationship, contributing to the baby's overall well-being.