Level: Foundational
Difficulty: Easy
Subtopic: Infant development
NCLEX: A 6-month-old infant at a well-child visit is being evaluated for developmental expectations for infant developme…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 6-month-old infant at a well-child visit is being evaluated for developmental expectations for infant development. Assessment data include the caregiver reports no social smile by 4 months. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Delegate all teaching without RN evaluation of learning needs.
D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
B. Assume understanding without checking literacy or readiness.
C. Delegate all teaching without RN evaluation of learning needs.
D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale
Correct answer: D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.