Maternity & Peds Health Promotion and Maintenance

A nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond?

"During the eighth week of the pregnancy." Rationale: During the eighth week of pregnancy the organ systems and other structures are developed to the extent that they take the human form; at this time the embryo becomes a fetus and remains so until birth. At the end of the second week of pregnancy, the developing cells are called an embryo. At the time of implantation, the group of developing cells is called a blastocyst. The embryo can be visualized on ultrasound before it becomes a fetus.

While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond?

"This is expected. Your baby is trying to focus." Rationale: Newborns' eye movements are uncoordinated, and the eyes may appear crossed as they try to focus. As the eye muscles mature, the apparent strabismus disappears. Stating that the baby's eyes seem fine discounts the mother's concern and is demeaning. Although it is true that the baby's eyes are crossed, the mother should be given an explanation for the apparent strabismus. Telling the mother that she is right and that the health care provider must be contacted is misinformation that will increase the mother's anxiety.

What is the appropriate parenting implication for an infant who is sleeping with the eyes closed and has regular breathing, no movements except for an occasional sudden bodily twitch, and no eye movement?

Continue usual house noises Rationale: Closed eyes, regular breathing, no movements except for an occasional sudden bodily twitch, and no eye movement indicate that the infant is in deep sleep. Therefore, the continuation of the usual house noises will not arouse the infant. Because the child is sleeping, feeding is not necessary unless the baby shows signs of hunger. The infant, if sleeping, may not need swaddling. Even if the infant is awakened by a loud noise, the infant will usually settle down independently. The infant can be picked up; however, when the infant is sleeping, there is no need to do so.

An 18-month-old toddler is admitted to the pediatric unit. The child has never been separated from the mother before this admission. What behavior does the nurse expect from the toddler?

Crying relentlessly and consoled by no one but a parent Rationales: The first stage of separation anxiety is protest, which is characterized by loud crying, rejection of all strangers, and inconsolable grief. Despair is indicative of the second stage of separation anxiety. Toddlers do not socialize well with peers. Smiling is not expected because an 18-month-old child is not easily consoled when separated from his or her parents

The mother of a 5-month-old infant with heart failure questions the necessity of weighing her baby every morning. The nurse's response is based on the fact that this daily information is important in determining:

Fluid retention Rationale: Fluid retention is reflected by an excessive weight gain in a short period. Inadequate cardiac output decreases blood flow to the kidneys and thus leads to increased intracellular fluid and hypervolemia. Although this assessment may add information to the data regarding kidney function, other assessments, such as hourly urine output, blood urea nitrogen concentration, and creatinine level more significantly reflect kidney function. Weight gain resulting from nutritional intake is gradual and will not vary greatly on a day-to-day basis. Although weight is used to determine medication dosages, dosages do not need to be recalculated according to changes in daily weights.

A client at 22 weeks' gestation asks the nurse how to prevent back pain as her pregnancy progresses. What does the nurse suggest that she wear?

Low-heeled shoes Rationale: Low-heeled supportive shoes help maintain the body's center of gravity over the hips, limiting arching of the back that compensates for the increased weight in the abdominal area. Maternity girdles are no longer recommended. Support stockings may be helpful for a woman with varicose veins or ankle edema, but wearing them does not prevent back pain. Loose-fitting clothing may be comfortable but does not prevent back pain.

After a cesarean birth a nurse performs fundal checks every 15 minutes. The nurse determines that the fundus is soft and boggy. What is the priority nursing action at this time?

Massaging the client's fundus Rationale: Gentle massage stimulates muscle fibers, resulting in firming the tone of the fundus; it also helps expel any clots that may be interfering with contraction of the fundus. Elevating the client's legs will increase return of blood from the extremities but will not improve the tone of the client's fundus. Increasing the client's oxytocin drip rate will be done if uterine massage is ineffective. Examining the client's perineum for bleeding should not be the first action at this time; gentle massage to contract the fundus is the priority.

The mother of a 5-month-old infant asks the nurse in the well-baby clinic to tell her the order in which new foods should be introduced. The nurse responds that once infant cereals have been introduced, the foods that are best for an infant of this age include:

Strained vegetables Rationale: Solid foods that are least likely to cause an allergic reaction are introduced first. Some practitioners prefer to introduce infant vegetables as the second food after cereal; others prefer fruits. New foods should be introduced one at a time so an allergic reaction to a specific food can be identified if it occurs. Eggs, fish, and meat are protein foods that are known to be allergenic to susceptible individuals; they should be introduced after the infant has tolerated a variety of baby cereals, fruits, and vegetables.

The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections?

Structural differences between Eustachian tubes of younger and older children Rationales: The Eustachian tube in young children is shorter and wider, allowing a reflux of nasopharyngeal secretions. Immunological differences are not a factor in the development of otitis media. There is no difference in the function of the Eustachian tube among age groups. The size of the middle ear does not play a role in the occurrence of otitis media in young children