The nurse is observing an infant and notes that the infant is restless, wide-awake but quiet. The mother reports that her baby often is awake for hours at a time and is very fidgety. How would the nurse respond to her observation?
Since the infant is often awake for long periods, the nurse needs to talk to the doctor about prescribing some medication to calm the child.
The nurse should report the infant’s behavior to her supervisor for further investigation.
The nurse should do a more in-depth investigation to determine why the infant is awake so much and is restless.
Since the mother reports that the infant’s behavior is normal, there is no need for further investigation.
The Correct Answer is C
Choice A reason: Prescribing medication to calm an infant is premature without investigating the cause of restlessness and prolonged wakefulness. An in-depth assessment identifies underlying issues like medical or environmental factors, making this reactive and incorrect compared to a thorough evaluation of the infant’s behavior.
Choice B reason: Reporting to a supervisor is unnecessary before assessing the infant’s restlessness and wakefulness. Conducting an in-depth investigation allows the nurse to gather data on potential causes, making this less direct and incorrect compared to initiating a thorough assessment of the infant’s condition first.
Choice C reason: Restlessness and prolonged wakefulness in an infant warrant an in-depth investigation to identify causes like medical issues, feeding problems, or environmental factors. This aligns with pediatric nursing assessment principles, ensuring a comprehensive approach to the infant’s behavior, making it the correct response for the nurse.
Choice D reason: Assuming the behavior is normal because the mother reports it dismisses potential underlying issues causing restlessness. An in-depth investigation is needed to rule out medical or environmental factors, making this incorrect, as it risks overlooking conditions requiring intervention in the infant’s care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Prescribing medication to calm an infant is premature without investigating the cause of restlessness and prolonged wakefulness. An in-depth assessment identifies underlying issues like medical or environmental factors, making this reactive and incorrect compared to a thorough evaluation of the infant’s behavior.
Choice B reason: Reporting to a supervisor is unnecessary before assessing the infant’s restlessness and wakefulness. Conducting an in-depth investigation allows the nurse to gather data on potential causes, making this less direct and incorrect compared to initiating a thorough assessment of the infant’s condition first.
Choice C reason: Restlessness and prolonged wakefulness in an infant warrant an in-depth investigation to identify causes like medical issues, feeding problems, or environmental factors. This aligns with pediatric nursing assessment principles, ensuring a comprehensive approach to the infant’s behavior, making it the correct response for the nurse.
Choice D reason: Assuming the behavior is normal because the mother reports it dismisses potential underlying issues causing restlessness. An in-depth investigation is needed to rule out medical or environmental factors, making this incorrect, as it risks overlooking conditions requiring intervention in the infant’s care.
Correct Answer is C
Explanation
Choice A reason: Notifying a religious leader may provide spiritual support but is secondary to facilitating the family’s immediate grieving by viewing the deceased. Cleaning the body allows closure, making this less urgent and incorrect for the initial nursing action to support the family’s grief in the ER.
Choice B reason: Arranging funeral home transfer is logistical and less immediate than helping the family process loss through viewing the deceased. Preparing the body supports emotional closure, making this secondary and incorrect for the initial action to aid the family’s grieving process in the ER.
Choice C reason: Cleaning and presenting the deceased allows the family to view their loved one, facilitating closure and beginning the grieving process. This aligns with trauma nursing principles for supporting bereaved families, making it the best initial action in this tragic car accident scenario.
Choice D reason: Presenting personal belongings is meaningful but less critical than allowing the family to see the deceased, which supports immediate grief processing. Body preparation takes precedence for closure, making this less impactful and incorrect for the initial grieving support action in the ER.
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