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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Consistent rules help toddlers understand expectations, fostering predictable behavior and security. This aligns with pediatric developmental discipline strategies, making it a correct point to teach parents, as it supports effective toddler behavior management and reduces confusion during disciplinary interactions.
Choice B reason: Scolding with labels like “naughty” shames toddlers, hindering self-esteem and learning. Consistency and boundaries teach effectively without negativity, making this incorrect, as it promotes ineffective discipline that may emotionally harm toddlers rather than guide their behavior constructively in the class.
Choice C reason: Toddlers begin learning self-control around 2, not 3-4 years, through guidance and boundaries. Consistency supports this, making this incorrect, as it underestimates toddlers’ capacity for early self-regulation when provided with appropriate disciplinary structures in a parenting education setting.
Choice D reason: Immediate addressing of behavior is ideal but not always necessary; delayed correction can still teach toddlers. Consistency and boundaries are more foundational, making this partially correct but incorrect for prioritization compared to the broader principles of discipline taught in the class.
Choice E reason: Boundaries provide toddlers with structure, promoting safety and behavioral learning even at a young age. This aligns with pediatric discipline principles, making it a correct point to emphasize, as it helps parents establish a framework for effective toddler behavior management in daily interactions.
Correct Answer is A
Explanation
Choice A reason: Holding the buttocks together for 1-2 minutes after suppository insertion prevents expulsion, ensuring the medication is absorbed in a 3-month-old. This aligns with pediatric medication administration protocols, making it the correct intervention to assure effective delivery of the rectal suppository in this infant.
Choice B reason: Pre-warming the suppository is not standard, as it may soften excessively, complicating insertion. Holding the buttocks ensures retention, directly impacting absorption, making this less effective and incorrect compared to the critical step of preventing expulsion in a 3-month-old during suppository administration.
Choice C reason: Using the index finger is inappropriate for an infant, as the pinky finger is safer for their small rectum. Holding the buttocks ensures medication retention, making this unsafe and incorrect compared to the prioritized intervention for effective suppository administration in a 3-month-old child.
Choice D reason: Placing the child on the abdomen may aid positioning but does not ensure suppository retention like holding the buttocks. Retention is critical for absorption, making this less essential and incorrect compared to the direct intervention of securing the suppository in place post-insertion for the infant.
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