The mother of a 4-year-old child tells a nurse that her child is reluctant to go to bed at night.
Which of the following responses should the nurse make?
Allow your child an additional 30 minutes of play time before bed.
Let your child sleep in your bed with you.
Keep a night light on in your child's room.
Stay with your child until he is asleep if he begins to cry.
The Correct Answer is C
Choice A rationale
Allowing an additional 30 minutes of play before bedtime can lead to overstimulation and delay the child's ability to settle down for sleep. Consistent bedtime routines are crucial for
establishing healthy sleep patterns in children.
Choice B rationale
Letting the child sleep in the parent's bed can create dependency and difficulty in establishing the child's own sleep routine and space. This practice can disrupt both the parent's and
child's sleep in the long term.
Choice C rationale
Keeping a night light on provides a sense of security and comfort for a child who may be afraid of the dark. This helps the child feel safe and can ease the transition to bedtime.
Choice D rationale
Staying with the child until they fall asleep, especially if crying, can reinforce the behavior and make it harder for the child to develop self-soothing skills. It can lead to increased
dependency on the parent's presence to fall asleep.
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Correct Answer is A
Explanation
Choice A rationale
Ensuring the client's weights are hanging freely from the bed is crucial in maintaining the proper amount of traction force. This prevents complications and ensures that the traction is effective in reducing the fracture and alleviating pain.
Choice B rationale
Checking the client's bony prominences every 12 hours is important for preventing pressure ulcers and skin breakdown. However, the timing might need to be more frequent depending on the client's overall health and risk factors.
Choice C rationale
Cleansing the client's pin sites with povidone-iodine is a common practice to prevent infection. However, current guidelines often recommend alternative cleaning solutions, such as chlorhexidine, due to better evidence of efficacy.
Choice D rationale
Loosening the knots on the ropes if the client is experiencing pain can compromise the effectiveness of the traction. Adjustments should be made by a healthcare professional to ensure the correct amount of force is applied without causing additional harm.
Correct Answer is A
Explanation
Choice A rationale
Applying a sterile, moist dressing on the sac helps prevent infection and keeps the tissue moist, promoting healing.
Choice B rationale
Monitoring the infant's temperature rectally can increase the risk of infection and is not recommended.
Choice C rationale
Encouraging the guardian to cuddle with the infant is important for bonding but doesn't directly address the care of myelomeningocele.
Choice D rationale
Maintaining the infant in a supine position can put pressure on the sac, increasing the risk of rupture and infection.