A client is concerned that her newborn has “crossed eyes.” Which of the following statements is a therapeutic response by the nurse?

I will call your provider and report your concerns.

I will take your baby back to the nursery for an examination.

Newborns lack the necessary muscle control to regulate eye movement.

This condition is easily treated by patching your baby's eyes.

Answer and Explanation

The Correct Answer is C

Choice A reason: This statement is not therapeutic. It does not address the client's feelings or provide reassurance. It may also imply that the nurse is not competent to handle the situation.

Choice B reason: This statement is not therapeutic. It does not explain the reason for taking the baby back to the nursery or involve the client in the decision. It may also increase the client's anxiety and interfere with bonding.

Choice C reason: This statement is therapeutic. It provides factual information and education about the normal development of the newborn's eyes. It also reassures the client that the condition is temporary and not a cause for concern.

Choice D reason: This statement is not therapeutic. It is inaccurate and misleading. Patching the baby's eyes is not a treatment for crossed eyes. It may also cause harm by depriving the baby of visual stimulation and interfering with eye alignment.

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Correct Answer is C

Explanation

Choice A reason: This statement is false. A small for gestational age newborn does not increase the risk of postpartum hemorrhage. In fact, a large for gestational age newborn or a multiple gestation can cause overdistension of the uterus and impair its ability to contract after delivery, leading to postpartum hemorrhage.

Choice B reason: This statement is false. Gestational hypertension does not directly increase the risk of postpartum hemorrhage. However, it can be associated with other complications such as preeclampsia, placental abruption, or coagulopathy that can cause bleeding after delivery.

Choice C reason: This statement is true. A precipitous birth is a birth that occurs in less than 3 hours from the onset of labor. It can cause trauma to the birth canal, uterine atony, or retained placental fragments, resulting in postpartum hemorrhage.

Choice D reason: This statement is false. A two-vessel umbilical cord is a cord that has one artery and one vein instead of the normal two arteries and one vein. It does not increase the risk of postpartum hemorrhage, but it can indicate other congenital anomalies or fetal growth restriction.

A. Stimulate the infant to cry. B. Dry the infant off and cover the head. C. Clamp the umbilical cord. D. Clear the respiratory tract.

Correct Answer is B

Explanation

Choice A reason: This statement is false. Stimulating the infant to cry is not the first action that the nurse should perform. Crying can cause the infant to lose heat and increase the risk of hypothermia. The nurse should first dry the infant off and cover the head to prevent heat loss and then assess the respiratory status.

Choice B reason: This statement is true. Drying the infant off and covering the head is the first action that the nurse should perform. This helps to prevent heat loss through evaporation and radiation and maintain the infant's body temperature. The nurse should also place the infant on the mother's chest or abdomen to promote skin-to-skin contact and bonding.

Choice C reason: This statement is false. Clamping the umbilical cord is not the first action that the nurse should perform. The nurse should wait until the cord stops pulsating before clamping and cutting it. This allows the infant to receive more blood from the placenta and reduce the risk of anemia and hemorrhage.

Choice D reason: This statement is false. Clearing the respiratory tract is not the first action that the nurse should perform. The nurse should only suction the mouth and nose of the infant if there is evidence of meconium, blood, or mucus that can obstruct the airway. The nurse should first dry the infant off and cover the head to prevent heat loss and then assess the respiratory status.

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A client is concerned that her newborn has “crossed eyes.” Which of the following statements is a therapeutic response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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