A nurse is caring for a client in the maternal newborn unit.
Which of the following actions should the nurse take?
Assess the client’s socioeconomic status.
Collect a dietary history.
Determine the best method of contraception for the client.
Perform unbiased teachings based on the client’s needs.
The Correct Answer is D
Choice A rationale
Assessing the client’s socioeconomic status is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice B rationale
Collecting a dietary history is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice C rationale
Determining the best method of contraception for the client is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice D rationale
Performing unbiased teachings based on the client’s needs is the primary action the nurse should take in the maternal newborn unit. This ensures that the client receives accurate and relevant information tailored to their specific situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Applying a corticosteroid cream is not appropriate for acute perineal pain. It is more suitable for chronic inflammation or skin conditions.
Choice B rationale
Increasing fluid intake is beneficial for overall health, but it does not directly address acute perineal pain.
Choice C rationale
Catheterizing the bladder is not indicated for perineal pain unless there is a specific issue with urinary retention.
Choice D rationale
Offering an ice pack helps reduce swelling and numb the area, providing immediate relief for acute perineal pain. It is a standard intervention for postpartum perineal discomfort.
Correct Answer is []
Explanation
Based on the provided information, here’s the completed diagram:
Potential Condition
- Neonatal abstinence syndrome
Actions to Take
- Reinforce with the parent to feed the newborn
- Anticipate a prescription to obtain a capillary blood sample
Parameters to Monitor
- Respiratory status
- Temperature
Congenital Syphilis
- Reasoning: The mother’s syphilis was treated successfully in the first trimester, and her subsequent tests (VDRL and RPR) were negative. This indicates that the infection was resolved, making congenital syphilis unlikely.
Hypoglycemia
- Reasoning: While some symptoms like jitteriness and weak cry could suggest hypoglycemia, the newborn’s weight (4,366 g) and the absence of other typical signs like lethargy or seizures make this less likely. Additionally, there is no mention of a blood glucose test result indicating hypoglycemia.
Kernicterus
- Reasoning: Kernicterus is a severe form of jaundice caused by high bilirubin levels. The newborn’s symptoms (jitteriness, weak cry, mottled extremities, acrocyanosis) do not align with the typical presentation of kernicterus, which includes severe jaundice, lethargy, and high-pitched crying. There is also no mention of elevated bilirubin levels.
Neonatal Abstinence Syndrome (NAS)
- Reasoning: The newborn’s symptoms (jitteriness, weak cry, rapid respirations, restlessness, difficulty feeding, and decreased muscle tone) are consistent with NAS, which can occur due to maternal substance use during pregnancy. The positive urine drug screen for marijuana supports this diagnosis
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