Author Question: The nurse is planning an educational session for maternalchild health unit nurses to cross-train ... (Read 81 times)

Bernana · **on:** Jun 28, 2018

The nurse is planning an educational session for maternalchild health unit nurses to cross-train them for providing home-based care after discharge.

Which statements indicate that additional teaching is required? The behavioral assessment: (Select all that apply.) 1. Should be done as soon after birth as possible.
2. Can be performed without input from parents.
3. May be incomplete in a one-hour home visit.
4. Includes orientation and motor activity.
5. May detect neurological anomalies.
Correct

Question 2

The nurse is working with a family that has just delivered their third child, at 33 weeks' gestation. The mother tells the nurse, This baby doesn't turn his head and suck like the older two children did.

Why? The best response by the nurse is: 1. Every baby is different. This is just one variation of normal that we see on a regular basis.
2. This baby might not have a rooting or sucking reflex because she is premature.
3. When she is wide awake and alert, she will probably root and suck even if she is early.
4. She may be too tired from the birthing process and need a couple days to recover.

briezy · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

1, 2
Rationale:
1. The behavioral exam is not accurate until about the third day of life. Newborns have disorganized behavior in the first days after birth.
2. Parental input is required to fully understand the infant's behaviors that are not observed by the health care team.
3. A full behavioral assessment requires seeing the infant in several sleep/alert stages, which is not likely to take place in a one-hour home visit.
4. Orientation to visual and auditory clues and motor activity are portions of the behavioral assessment.
5. This statement is true.

Answer to Question 2

2
Rationale:
1. Although each baby is unique and different from her siblings, this answer does not indicate that prematurity is the cause of the lack of root and suck reflexes.
2. Preterm babies often have a poor or absent root and suck reflex. They also might not have a swallow reflex, and might require tube feedings temporarily.
3. This statement is true of term infants, but this infant is preterm, and the prematurity is the cause of the lack of rooting and sucking.
4. Although birth is stressful to newborns, and some require a day or two of recovery to become fully alert, this infant is preterm, and the prematurity is the cause of the lack of rooting and sucking.