A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse?

"I will take your baby to the nursery for further examination."

"This occurs because newborns lack muscle control to regulate eye movement."

"I will call your primary care provider to report your concerns."

"This is a concern, but strabismus is easily treated with patching."

Answer and Explanation

The Correct Answer is B

A. "I will take your baby to the nursery for further examination": This response may unnecessarily alarm the mother and does not address the typical, benign nature of the concern. Newborns can occasionally exhibit crossed eyes, which is often a normal developmental stage.

B. "This occurs because newborns lack muscle control to regulate eye movement": This is the most accurate and comforting response. It explains that eye crossing (strabismus) is common in newborns due to their immature eye muscles, and it usually resolves as the baby grows and gains more muscle control.

C. "I will call your primary care provider to report your concerns": While it's important to address concerns, this response may be premature. Eye crossing in newborns is generally normal, and immediate consultation with the primary care provider isn't necessary unless the condition persists beyond a few months or worsens.

D. "This is a concern, but strabismus is easily treated with patching": This response is not appropriate for a newborn. While strabismus can be treated in older children, it is usually normal in newborns and does not require immediate treatment like patching.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Dry the infant off and cover the head: This helps prevent heat loss through evaporation, which is important, but it is not the first action. Establishing a patent airway takes priority over thermal regulation in the immediate moments after birth.

B. Clear the respiratory tract: This is the first and most critical step to ensure that the newborn can breathe effectively. Suctioning the mouth and nose removes mucus or amniotic fluid that may obstruct airflow. Airway patency must be established before any other intervention.

C. Cut the umbilical cord: Cord clamping and cutting should be delayed to allow placental blood transfer and improve the newborn’s iron stores. It is not prioritized over ensuring adequate breathing and oxygenation.

D. Stimulate the infant to cry: While stimulating the infant promotes lung expansion, this should follow airway clearance. Clearing the airway enables effective stimulation and reduces the risk of aspiration.

A. Fundus soft, 2 cm above the umbilicus B. Fundus soft, 1 cm to the right of the umbilicus C. Fundus firm, at the level of the umbilicus D. Fundus present, to the left of the umbilicus

Correct Answer is C

Explanation

A. Fundus soft, 2 cm above the umbilicus: A soft (boggy) fundus is an abnormal finding and suggests uterine atony, which can lead to postpartum hemorrhage. At 12 hours postpartum, the fundus may be at or slightly above the umbilicus, but it should be firm. A soft uterus requires immediate intervention such as fundal massage.

B. Fundus soft, 1 cm to the right of the umbilicus: Deviation of the uterus to the right side often indicates a full bladder, which can impede uterine contraction and increase the risk of hemorrhage. A soft and displaced fundus at 12 hours postpartum is concerning and not expected.

C. Fundus firm, at the level of the umbilicus: This is the expected and normal finding 12 hours postpartum. The uterus should be firm to ensure effective involution and to prevent hemorrhage. It typically remains at the level of the umbilicus or slightly above before beginning its descent into the pelvis over the next several days.

D. Fundus present, to the left of the umbilicus: Similar to right deviation, leftward displacement may suggest bladder distention or other structural influences. The fundus should remain midline and firm. Any lateral deviation is a cue for the nurse to assess bladder status and encourage voiding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Correct Answer is B

Explanation

A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

Rho immune globulin will be ordered postpartum if which situation occurs?

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

For an infant experiencing symptoms of drug withdrawal, which intervention should be included in the plan of care?

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?