A nurse asks the mother to undress her four-month-old infant. The nurse observes the mother taking off several layers of clothing, knowing that the outdoor temperature is 70°F. Which of these statements should the nurse make to the mother?
1. "When you leave the office, only put one layer of clothing on your baby."
2. "My, you are dressing your infant warmly today."
3. "Did you think it was it cold when you left your home this morning?"
4. "I see that you have many layers of clothing on your baby. This could cause your baby's temperature to rise."
4
Rationale 1: Telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time; this statement is not helpful to the mother.
Rationale 2: Making a statement on how warmly the child is dressed will not necessarily accomplish the goal of informing the mother that she has overdressed the infant.
Rationale 3: This comment might cause the mother to become defensive, so it is not helpful to the mother.
Rationale 4: In this scenario, the mother has overdressed the infant. The nurse needs to inform the mother of this problem gently, and provide information to the mother on why it is a problem.
Global Rationale:
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A nurse established a new parent support group where new parents meet to share problems and solutions. After about 3 months, fewer people were attending. Which of the following actions should the nurse take next?
a. Accept that the new parents may now be comfortable in their role and no longer need a support group b. Bring in outside experts to give presentations on specific infancy development issues c. Change the format of the group meetings to include more time for socialization d. Suggest an ongoing educational program on infant and child development to renew interest in attending the group
To examine the macula, the nurse should do which of the following?
a. Ask the patient to avoid looking at the light. b. Trace an optic artery to its origin. c. Move the ophthalmoscope about 2 disk diameters temporally. d. Use the blue filter lens of the ophthalmoscope.
The nurse is caring for a client immediately following a cesarean section. When the baby is placed in her arms for the first time, the nurse notes that the mother touches him with her fingertips only, and recognizes this as:
A) an early sign of rejection. B) evidence that the mother is in pain. C) normal bonding progression. D) a symptom of postpartum blues.
A patient at 39 weeks' gestation presents at the labor and delivery suite saying that she is in labor. She reports that her water has not broken yet. Physical assessment reveals that the patient is not in true labor
The nurse explains that what the patient is feeling are Braxton Hicks contractions. What assessment findings would tell the nurse that these contractions are, in fact, Braxton Hicks? (Select all that apply.) A) 30 to 45 seconds in duration B) Fewer than five in 1 hour C) Not painful D) Resolve with position change E) Less than 30 seconds