The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What will the nurse do?
Schedule a full neurological evaluation.
Recommend follow-up in 30 days after documenting the regression.
Question the parents about changes in the child's activity schedule.
Document the findings and schedule an 18-month well-visit.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Maternal hypertension, or high blood pressure, is not directly associated with precipitous Labor. While hypertension can be a concern during pregnancy, it is not a primary complication resulting from a rapid Labor process. The nurse's focus would be on other specific complications that arise from precipitous Labor.
Choice B reason: Postpartum haemorrhage is a significant risk for patients experiencing precipitous Labor. Rapid Labor can lead to excessive uterine contractions, which might cause trauma to the birth canal, including lacerations and uterine atony (failure of the uterus to contract properly after delivery). These conditions can lead to significant blood loss and necessitate close monitoring and intervention to manage and mitigate the haemorrhage.
Choice C reason: Newborn hyperglycaemia, which refers to elevated blood sugar levels in the newborn, is not related to the process of precipitous Labor. This condition is more commonly associated with maternal diabetes and is not a typical complication the nurse would monitor for in this scenario.
Choice D reason: Premature rupture of membranes, which refers to the breaking of the amniotic sac before Labor begins, is not a complication resulting from precipitous Labor. It is a condition that can precede Labor but is not caused by the rapid progression of Labor. The nurse would be more concerned with managing complications directly related to the rapid Labor and delivery process.
Correct Answer is A
Explanation
Choice A reason: Providing patients with information regarding postpartum depression is crucial. Educating patients about the signs, symptoms, and treatment options for postpartum depression helps raise awareness and encourages early detection and intervention. Knowledge empowers patients and their families to seek help if needed.
Choice B reason: Encouraging patients to focus on positive aspects of pregnancy and birth is generally beneficial for emotional well-being, but it is not a specific strategy for addressing postpartum depression. Focusing solely on positive aspects may inadvertently dismiss the real and serious concerns of those experiencing postpartum depression.
Choice C reason: Consulting with the patient's spiritual advisor can be supportive, but it is not a primary strategy for addressing postpartum depression. While spiritual support can be a valuable component of holistic care, it should complement, not replace, medical and psychological interventions.
Choice D reason: Avoiding the assessment of suicidal thoughts to not upset the patient is dangerous and counterproductive. It is essential to assess for suicidal ideation in patients with postpartum depression to ensure their safety and provide appropriate interventions. Open and compassionate discussions about mental health are critical in addressing postpartum depression effectively.
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