Author Question: A triage nurse receives a call from a mother of an infant who appears pale, is breathing fast, and ... (Read 34 times)

EAugust · **on:** Jun 27, 2018

A triage nurse receives a call from a mother of an infant who appears pale, is breathing fast, and appears sleepy while feeding. What data would the nurse need to gather next?

1. Newborn's daily iron intake
2. Number of wet diapers a day
3. Skin color
4. Bilirubin level

Question 2

After assessing the data obtained from a pregnant teenager and her family, the nurse assigns the diagnosis of Family Coping, ineffective related to unanticipated pregnancy. Which of the following goals would be appropriate?

1. The teenager and family will participate in discussions regarding pregnancy.
2. The teenager and family will develop skills for parenting the infant.
3. The teenager and family will develop a trusting relationship with the health care providers.
4. The teenager and family will develop self-care skills for the pregnancy.

micaelaswann · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

1
Rationale:
1. An newborn who appears pale, appear sleepy or tires easily while feeding, and is tachycardic or tachypneic at rest could be deficient in iron.
2. The number of wet diapers a day would provide information concerning hydration.
3. Skin color would provide information about jaundice.
4. Bilirubin level would provide information about jaundice.

Answer to Question 2

1
Rationale:
1. Communication between family members is essential for them to understand each other's viewpoints. Joining in a discussion facilitated by the nurse will help begin the communication process for the family. Once communication has been established, making plans for the future can take place, which in turn promotes family coping.
2. Communication between family members is essential for them to understand each other's viewpoints. Joining in a discussion facilitated by the nurse will help begin the communication process for the family. Once communication has been established, making plans for the future can take place, which in turn promotes family coping.
3. Although trust in the health care providers is essential for the teen to accept teaching and have effective communication with the providers, this is an individual intervention aimed only at the pregnant teen, and not at the entire family.
4. Taking care of oneself or a newborn physically will not necessarily lead to family coping.