A nurse is caring for a toddler who is having difficulty sleeping during hospitalization.
Which of the following actions should the nurse take to promote sleep?
Encourage play exercises in the evening.
Turn off the room light.
Provide bedtime rituals.
Explain the source of the toddler's fears.
The Correct Answer is C
Choice A rationale
Encouraging play exercises in the evening can lead to overstimulation, which can make it harder for the toddler to fall asleep. Physical activity should generally be done earlier in the day to help with sleep later on.
Choice B rationale
Turning off the room light can create a dark environment conducive to sleep, but it doesn’t address the need for a calming routine, which is essential for young children’s sleep. Some children also feel safer with a nightlight.
Choice C rationale
Providing bedtime rituals can help signal to the toddler that it is time to wind down and sleep. Consistent rituals, such as reading a story or singing a lullaby, provide a sense of security and comfort.
Choice D rationale
Explaining the source of the toddler’s fears may be beyond the cognitive ability of a toddler and does not directly promote sleep. It’s better to provide comfort and reassurance through routine.
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Correct Answer is B
Explanation
Choice A rationale
Acrocyanosis is a common and typically benign condition in newborns, characterized by bluish discoloration of the hands and feet. It is not an immediate priority.
Choice B rationale
Respiratory distress is the priority assessment for a newborn immediately following a cesarean delivery. Ensuring the newborn has a patent airway and is breathing effectively is crucial for their survival and immediate well-being.
Choice C rationale
Hypothermia is a concern for newborns, but respiratory distress takes precedence as an immediate life-threatening condition.
Choice D rationale
Accidental lacerations can occur during a cesarean delivery, but they are usually not life-threatening and can be addressed after ensuring the newborn's respiratory status is stable. .
Correct Answer is D
Explanation
Choice A rationale
Administering vitamin K is important but not the immediate priority right after birth.
Choice B rationale
Administering eye prophylaxis is also necessary but comes after ensuring the newborn is dry to prevent heat loss.
Choice C rationale
Placing an identification bracelet is crucial but not as immediate as drying the skin to regulate the baby's temperature.
Choice D rationale
Drying the skin is the priority to prevent hypothermia by reducing evaporative heat loss right after birth