The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex.
Which response from his mother indicates a need for further teaching?
"He needs to get a medical alert identification.”.
"I will need to discuss this with his caregivers.”.
"A product's label indicates whether it is latex-free.”.
"He must avoid all contact with latex.”. —
The Correct Answer is C
Choice A rationale
A child with a diagnosed latex sensitivity, especially one with a history of myelomeningocele which carries a high risk, should absolutely wear medical alert identification. This ensures that emergency medical personnel and others are immediately aware of the allergy to prevent exposure to potentially life-threatening latex products.
Choice B rationale
It is crucial to inform all caregivers, including school nurses, teachers, and daycare providers, about the child's latex allergy. This allows them to implement proper avoidance strategies in their respective environments and recognize early signs of a reaction, ensuring the child's safety outside the home.
Choice C rationale
The statement that a product's label always indicates whether it is latex-free is incorrect and indicates a need for further teaching. Many items contain "hidden" latex, and labeling may not be mandatory or always comprehensive, requiring parents to exercise extreme caution and directly inquire about product composition.
Choice D rationale
Complete avoidance of all contact with products containing natural rubber latex is the only definitive way to prevent an allergic reaction in a sensitized child. Exposure, even to airborne particles from latex-containing materials, can trigger reactions ranging from mild skin irritation to severe anaphylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While quiet time is important for rest, allowing quiet time alone does not actively facilitate the mutual gaze and physical closeness that are critical for the initial, foundational stages of attachment. The most immediate and important action involves nurse-facilitated interaction that promotes specific bonding behaviors, which is a more direct path to attachment than passive rest.
Choice B rationale
The en face position, where the mother's face and the infant's face are approximately 30 cm apart and on the same vertical plane, is essential because it allows for direct, sustained eye contact. This mutual gaze is recognized as a fundamental element in promoting bonding and attachment by triggering reciprocal behavioral responses that are vital to the early parent-infant relationship formation.
Choice C rationale
Teaching concepts of bonding and attachment is an important nursing function, but it is an educational intervention that is secondary to the immediate, physical, and emotional facilitation of the actual bonding process. The most important action is to create the physical opportunity for bonding through direct sensory interaction immediately after delivery when the infant is in a quiet-alert state.
Choice D rationale
Assisting with breastfeeding is a crucial part of postpartum care and promotes bonding through skin-to-skin contact and physical closeness. However, the most universally important action immediately post-delivery is establishing eye contact and physical proximity (en face, skin-to-skin), as feeding may be delayed or not applicable to all mothers, making the en face position a broader, essential intervention.
Correct Answer is A
Explanation
Choice A rationale
Bone marrow aspiration and biopsy is the definitive diagnostic test for leukemia. This procedure involves extracting a small sample of the bone marrow, typically from the iliac crest in children, to analyze the type and percentage of immature blood cells (blasts) that characterize leukemia, thus confirming the diagnosis accurately.
Choice B rationale
A Computed Tomography (CT) scan uses X-rays to create cross-sectional images of the body. While useful for assessing solid tumors or detecting intracranial or chest disease complications of leukemia, it is not the primary or definitive diagnostic test for the condition itself, which is a cancer of the blood and bone marrow.
Choice C rationale
A Complete Blood Cell Count (CBC) is a crucial screening tool that often suggests the presence of leukemia by revealing abnormal white blood cell counts (often high or very low) and possibly anemia or thrombocytopenia. However, the CBC alone cannot confirm the diagnosis; it only indicates the need for definitive testing.
Choice D rationale
A Lumbar Puncture (spinal tap) is performed to collect cerebrospinal fluid (CSF) to check for the presence of leukemic cells that may have infiltrated the central nervous system, which is essential for staging and treatment planning, but it does not confirm the initial diagnosis of leukemia in the bone marrow.
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