Question

The nurse is preparing to assess a 10-month-old infant. He is sitting on his fathers lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?

A) Quickly proceeding with the assessment to minimize stress
B) Speaking loudly to distract and engage the infant
C) Approaching slowly and allowing the infant to become familiar with the nurse
D) Requesting the father to step away to reduce external stimulation

Answer 1

The nurse should approach slowly and allow the 10-month-old infant to become familiar before proceeding with the assessment to reduce stranger anxiety and create a sense of security.

Step-by-step explanation:

The most appropriate initial action by the nurse when preparing to assess a 10-month-old infant who appears to be afraid is C) approaching slowly and allowing the infant to become familiar with the nurse. This approach is based on understanding that infants at this age may exhibit stranger anxiety, which can be intensified by the presence of unfamiliar people. This time period is characterized by the infant forming attachments and developing trust with caregivers.

It's important for the nurse to create a sense of security and familiarity before proceeding with the assessment. Therefore, tactics like speaking softly, allowing the infant to observe the nurse, and possibly engaging with a familiar toy or object could aid in reducing the infant's fear and anxiety.

Rapidly proceeding with the assessment or speaking loudly could startle and increase the stress level of the infant, which is counterproductive to creating a calm environment. In contrast, gentle interaction supports the development of trust and eases the assessment process.