A home health nurse is caring for a newborn
Nurses’ Notes
3 weeks old:
Follow up newborn weight check. Parent is smoking a cigarette in the living room while infant sleeps. Parent reports the newborn is breastfeeding well. The newborn is asleep in their bassinet in the living room. Newborn currently asleep in prone position. Parent reports that the newborn sleeps in their bassinet in the parents' bedroom overnight
Vital Signs
3 weeks old:
- Temperature 36.9° C (98.4" F)
- Heart rate 138/min
- Respiratory rate 42/min
Parent is smoking a cigarette in the living room while infant sleeps.
Parent reports the newborn is breastfeeding well.
Newborn currently asleep in prone position.
Heart rate 138/min
The Correct Answer is ["A","C"]
Rationale
- Parent is smoking a cigarette in the living room while infant sleeps: Secondhand smoke increases the newborn’s risk for sudden infant death syndrome (SIDS), respiratory infections, and asthma. Infants should not be in an environment where smoking occurs, especially while sleeping. The nurse should provide education and interventions to reduce smoke exposure and promote a safe sleep environment.
- Newborn currently asleep in prone position: Placing a newborn in the prone position to sleep significantly increases the risk of SIDS. The American Academy of Pediatrics recommends that infants sleep on their backs on a firm, flat surface with no soft bedding or objects. The nurse should educate the parent about safe sleep practices and reposition the infant to a supine position for all sleep periods.
- The newborn breastfeeding well is not a finding requiring further intervention because it indicates the infant is feeding adequately and having sufficient wet and dirty diapers, which are signs of good hydration and nutrition.
- Heart rate 138/min. This heart rate is normal for newborns whose normal range is 120-160bpm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Collaborate with a prosthetist to teach the client about care of the prosthesis is important but not the first priority. Education about prosthesis care can only occur effectively if the home environment is safe and accessible.
B. Evaluate the client's home environment is correct because safety and accessibility at home are essential for preventing falls, injuries, or complications after a traumatic amputation. The nurse must assess for barriers such as stairs, narrow doorways, loose rugs, and bathroom accessibility. This assessment guides discharge planning and determines the need for home modifications, equipment, or additional support services. Safety must be prioritized before considering education or services.
C. Ask whether the client's insurance will cover home health services is important for planning but secondary to ensuring the home environment is safe. Coverage is irrelevant if the client’s home is unsafe for rehabilitation and prosthesis use.
D. Determine whether the client is eligible to go to a skilled nursing facility is part of discharge planning but is not the first priority. The need for a skilled facility is influenced by home safety, client mobility, and support systems, so home evaluation comes first.
Correct Answer is B
Explanation
Rationale:
A. Dandruff shampoo does not kill lice or nits effectively. High heat from a hair dryer is not a reliable or recommended method for lice eradication and may cause burns or scalp irritation.
B. This is a natural remedy sometimes used to suffocate lice. It is applied generously to the hair and scalp, covered with a shower cap for several hours, and then washed out. While not as consistently effective as pediculicides, it aligns with the guardian’s preference for nonchemical, natural treatment.
C. While cleaning personal items is important to prevent reinfestation, this action alone does not treat the lice on the child’s scalp. It is a supportive measure rather than a primary treatment.
D. Combing with a fine-tooth (nit) comb is an effective adjunctive method, especially after treatment, but it is time-consuming and typically used in combination with another treatment. It may not be sufficient alone to eliminate lice entirely.
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