Test Bank for Maternal and Child Health Nursing

16. The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital? A) Baby has a changing area. B) Kitchen has a refrigerator. C) Windows are covered with screens. D) Baby sleeps with the mother in bed. Ans: D Feedback: Evidence that an inadequate home environment assessment was performed as baby is sleeping with the mother. The American Academy of Pediatrics recommends newborns have their own crib as a step toward preventing sudden infant death syndrome. The baby having a changing area, the kitchen has a refrigerator, and the windows are covered with screens indicate that the home environment is adequate to support the needs of a newborn 17. A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg intramuscularly. What should the nurse do when providing this medication to the newborn? A) Administer the medication in the deltoid muscle. B) Administer the medication into the anterolateral muscle. C) Provide the medication immediately before breastfeeding. D) Notify the physician for swelling and irritation at the injection site. Ans: B Feedback: Vitamin K should be administered into a large muscle such as the anterolateral muscle of the newborn's thigh. The deltoid muscle is not used for intramuscular injections in the newborn. The medication should be given so as not to interrupt breastfeeding. Swelling and irritation at the injection site is a possible adverse reaction and does not necessarily need to be reported to the physician. 18. A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears? A) Only people who are known to the staff are permitted in the nursery. B) Keeping the baby in the mother's room at all times is the best approach. C) Both the mother and infant have identification bands that need to match. D) Security questions everyone before permitting them access to the hospital. Ans: C Feedback: Hospitals have an identification banding system where the mother's and the infant's identification bands are to match. Only people with proper hospital identification should be permitted into the nursery. Keeping the baby in the mother's room at all times could be dangerous because the baby could be left unattended, permitting someone an opportunity to abduct the infant. Security does not routinely question everyone before permitting them access to the hospital. 13. The nurse is caring for a school-age child who does not speak English. During the night, a procedure needs to be done and an interpreter is not available. What should the nurse do to teach the patient about this procedure? A) Tell the parents to tell the child what will be happening. B) Draw a picture of the procedure using an anatomically correct figure. C) Call the interpreter on the phone to explain the procedure to the child. D) A child of this age does not require a detailed explanation, just perform the procedure. Ans: B Feedback: If instructions are to be provided to a child who does not understand English, and an interpreter is not present, the nurse can use draw a picture to explain the procedure. The nurse does not need to involve the parents in this teaching need. The interpreter is unavailable. It is not known if the interpreter can be reached by telephone. School-age children need to be instructed prior to performing any procedure. 1. The nurse is discussing a pending hospitalization of an 8-month-old infant with the parents. What should the nurse encourage the parents to do when preparing the child for this hospitalization? A) Pack her favorite toy. B) Buy a new pair of soft pajamas. C) Read her a story on hospitalization. D) Let her watch her suitcase being packed. Ans: A Feedback: Because an infant cannot understand explanations of surgery or treatments, oral preparation is minimal. Remind parents to pack special items such as a favorite toy because this object provides a special kind of security for which there is no substitute. The infant is not old enough to appreciate a new pair of pajamas. Reading a story will have no meaning to the child. The child will not understand a suitcase being packed. 2. The mother of an infant is unable to visit the child in the hospital for 3 days. At first, the baby cries relentlessly but then becomes quiet and withdrawn. What reaction does the nurse identify as occurring with this child? A) The infant is fatigued. B) The infant is developing a sense of denial. C) The infant is confused about being hospitalized. D) The infant is ill, which is causing the change in behavior. Ans: B Feedback: In separation anxiety, the stage of protest is when the child cries loudly and is unable to be comforted. In denial, the child is silent with an expressionless face. The infant's behavior is not because of fatigue, confusion, or the illness.