During the health history, the mother of a 4-month-old child ...

[Melani1276]

During the health history, the mother of a 4-month-old child tells the nurse she is concerned that her baby is not doing what he should be at this age. Which response by the nurse would be most appropriate?
 
  A) I can tell you more after his physical.
  B) Fill out this questionnaire first.
  C) Tell me what concerns you.
  D) All mothers worry, but he seems well.

Question 2

A woman telephones her health care provider and reports that her waters just broke. Which suggestion by the nurse would be most appropriate?
 
  A) Call us back when you start having contractions.
  B) Come to the clinic or emergency department for an evaluation.
  C) Drink 3 to 4 glasses of water and lie down.
  D) Come in as soon as you feel the urge to push.

[bimper21]

Answer to Question 1

C
Response:
Asking about the mother's concerns is assessment and is the first thing the nurse should do. The mother has intimate knowledge of the infant and can provide invaluable information that can help structure the nurse's assessment. Relying on the physical assessment ignores the value of the mother's input. A screening questionnaire is no substitute for a developmental assessment. Minimizing the mother's concerns reduces communication between the mother and the nurse.

Answer to Question 2

B
Response:
When the amniotic sac ruptures, the barrier to infection is gone and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.

[Melani1276]

Thank you

[bimper21]

No problemo