The nurse is evaluating an 18-month-old client.
Which data would indicate to the nurse that the child is meeting tasks according to Erikson's Stages of Psychosocial Development? Select all that apply.

Choice A rationale

Throwing away all stuffed animals is an unnecessary and extreme measure. The lice and nits are unlikely to survive for an extended period off the host. Sealing the items in an airtight bag for a specific duration is a more cost-effective and practical method to ensure any lice or nits are suffocated and die, preventing re-infestation.

Choice B rationale

Changing bed linen every 12 hours is not scientifically necessary. Lice and nits can survive for a limited time off the scalp, but not long enough to warrant such frequent changes. Changing and washing bedding and clothing in hot water and drying them on high heat once a day for a few days is sufficient to kill any lice or nits that may have fallen off.

Choice C rationale

Sealing all non-washable items in airtight bags for two weeks is a highly effective method. Lice and nits require a human host for survival, feeding on blood. Without a host, they will die from starvation within one to two weeks. Sealing items suffocates any remaining lice and ensures that any nits that may hatch will also die without a food source.

Choice D rationale

Soaking all hair items in alcohol is not a standard or recommended practice. While alcohol can be a disinfectant, it is not the primary method for treating lice and may damage the items. Combing with a fine-toothed nit comb, washing in hot water, or sealing items are more proven and safer methods for eradicating lice from personal belongings and preventing re-infestation.

Choice A rationale

Preparing for a vaginal delivery is not the first action to perform based on a specific fetal monitor pattern. The initial step is to identify the cause of the non-reassuring pattern and attempt to correct it with less invasive measures. Preparing for delivery is a more advanced intervention and is considered only after other interventions, such as changing maternal position, administering oxygen, and providing intravenous fluids, have failed to resolve the fetal distress pattern.

Choice B rationale

Administering oxygen at 3 liters via nasal cannula is a supportive measure to increase fetal oxygenation. However, it is not the first action. The most immediate and effective first step is to improve uterine blood flow and placental perfusion by changing the maternal position. Decreasing pressure on the vena cava and aorta is a more direct way to improve oxygen delivery to the fetus than administering oxygen to the mother.

Choice C rationale

Turning the client or asking them to turn on their side is the first action. This maneuver relieves pressure on the maternal vena cava and aorta, which can be caused by the gravid uterus. By improving venous return and cardiac output, this position change directly increases blood flow to the placenta. This enhanced placental perfusion often corrects non-reassuring fetal heart rate patterns, such as late decelerations, by improving oxygen delivery to the fetus.

Choice D rationale

Performing a vaginal exam to assess for the umbilical cord is an important assessment, but it is not the first action. While a vaginal exam is necessary to rule out a prolapsed cord, especially with sudden changes in the fetal heart rate, it should be done after attempting the less invasive and immediate intervention of changing the client's position. Position change is a quick and non-invasive way to improve fetal oxygenation and is the priority initial step.