A nurse is assisting the guardians of a newborn with the transition to parenthood. Which of the following actions should the nurse take?

Promote bonding by encouraging the guardians to formula feed their newborn

Encourage guardians to allow relatives to provide the majority of the care for their newborn.

Ensure guardians know that criticism of newborn care is acceptable.

Inform guardians how to respond to their newborn's cues

Answer and Explanation

The Correct Answer is D

A. Promote bonding by encouraging the guardians to formula feed their newborn: Bonding occurs through close physical contact, responsiveness, and nurturing care, regardless of the feeding method. Bonding is important regardless of feeding method, but feeding choice should be based on the guardians’ preference, not directed solely by the nurse. Formula feeding is not necessary for promoting bonding.

B. Encourage guardians to allow relatives to provide the majority of the care for their newborn: Guardians should be encouraged to provide the majority of the newborn's care themselves to strengthen attachment and build confidence in their parenting abilities.

C. Ensure guardians know that criticism of newborn care is acceptable: Criticism can undermine the guardians' confidence and create stress. Support and positive reinforcement are important for helping new parents feel secure in their roles.

D. Inform guardians how to respond to their newborn's cues: Teaching guardians how to recognize and respond to their newborn's cues, such as hunger, discomfort, or need for interaction, promotes bonding, supports emotional development, and strengthens the parent-newborn relationship.

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Correct Answer is C

Explanation

A. Inability to read: Difficulty reading is not a hallmark symptom of delirium. It may be associated with visual impairment, literacy issues, or chronic cognitive decline such as dementia, but delirium is primarily characterized by acute mental status changes, not isolated reading difficulties.

B. Echopraxia: Echopraxia, the involuntary imitation of another person’s movements, is typically associated with schizophrenia or other severe psychiatric disorders. It is not a defining feature of delirium, which primarily affects attention, awareness, and cognition rather than imitation behaviors.

C. Acute onset of confusion: Delirium is distinguished by a sudden, acute onset of confusion and fluctuating levels of consciousness. Clients may exhibit disorganized thinking, poor attention, and impaired awareness, which are hallmark features that help differentiate delirium from chronic conditions like dementia.

D. Aphasia: Aphasia, or loss of the ability to understand or express speech, is more commonly related to neurological injuries such as stroke. While speech may be disorganized during delirium, the specific loss of language function like aphasia is not a primary or expected feature of this acute condition.

A. Ask the client's family about cultural or religious practices regarding postmortem care. B. Remove the client's dentures from their mouth before rigor mortis begins. C. Turn on all the lights in the room before the family views the client's body. D. Position the client's bed flat without a pillow under their head.

Correct Answer is A

Explanation

A. Ask the client's family about cultural or religious practices regarding postmortem care: Respecting the client's and family's cultural and religious preferences is an important aspect of providing dignified and individualized postmortem care. Some practices may have specific rituals that should be honored.

B. Remove the client's dentures from their mouth before rigor mortis begins: Dentures are usually placed back into the client's mouth, not removed, to maintain a natural facial appearance and support the facial structure before rigor mortis sets in.

C. Turn on all the lights in the room before the family views the client's body: Creating a calm, peaceful environment is preferred when the family views the body. Harsh lighting may feel overwhelming or intrusive during such an emotional time.

D. Position the client's bed flat without a pillow under their head: Elevating the head of the bed slightly and placing a pillow under the head can help prevent blood from pooling in the head and face, preserving a more natural appearance. Leaving the bed flat is not ideal.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

A nurse is assisting the guardians of a newborn with the transition to parenthood. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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