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The nurse must assess a 10-month-old infant. The infant is sitting on the father's lap and appears to be afraid of the nurse and of what might happen next. Which initial action by the nurse would be most appropriate?

a.Initiate a game of peek-a-boo.
b.Ask father to place the infant on the examination table.
c.Undress the infant while he is still sitting on his father's lap.
d.Talk softly to the infant while taking him from his father.

User BJ Clark
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Final answer:

The nurse should initiate a game of peek-a-boo to ease the 10-month-old infant's stranger anxiety and establish a trustful interaction before proceeding with the assessment. This approach respects the infant's developmental stage, reduces stress, and allows observation in a non-threatening manner.

Step-by-step explanation:

The most appropriate initial action by the nurse when assessing a 10-month-old infant who appears to be afraid would be to initiate a game of peek-a-boo. This approach acknowledges the developmental stage where infants have begun to exhibit stranger anxiety and the need for comfort from familiar figures such as parents. By engaging in a familiar and non-threatening game like peek-a-boo, the nurse can build rapport with the infant in a playful and gentle manner, creating a more conducive environment for examination.



It's crucial to understand that, according to Piaget's theory, at around ten months, infants are beginning to display stranger anxiety. This is the developmental stage where infants may show distress around unknown individuals, which is why the nurse should seek to establish trust in a non-invasive and soothing way. Given that direct, unfamiliar interactions might escalate the anxiety, games that facilitate interaction while respecting the infant's comfort zone are ideal. Initiating peek-a-boo utilizes the caregiver's presence as a comforting element, helping reduce the infant's anxiety while also creating an engaging interaction that allows the nurse to observe the infant's responses and behaviors. This could lead to a better assessment without causing undue stress to the infant.

User Ryan Tam
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