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.

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Correct Answer is A

Explanation

A. Massaging the woman's fundus: The highest priority when a woman saturates a perineal pad in 15 minutes, suggesting postpartum haemorrhage, is to assess and manage the uterine tone immediately. Uterine atony is the most common cause of postpartum hemorrhage. Fundal massage is the first-line intervention to stimulate uterine contraction, reduce bleeding, and potentially control the hemorrhage before it worsens.

B. Beginning an intravenous (IV) infusion of Ringer's lactate solution: While fluid resuscitation may be necessary if significant blood loss continues, it does not address the primary cause of the bleeding. Starting IV fluids supports circulation but should occur after or concurrently with fundal massage, not before it.

C. Assessing the woman's vital signs: Vital signs provide important information about the woman’s circulatory status but do not directly address the bleeding. Vital signs should be monitored closely, but the priority is to stop the hemorrhage, beginning with fundal massage.

D. Calling the woman's primary health care provider: While the provider should be notified after initial emergency interventions have been started, immediate actions to control bleeding, such as fundal massage, take precedence. Delaying action can lead to rapid deterioration in a postpartum hemorrhage scenario.

A. "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps." B. "I will place my baby on his stomach when he is sleeping." C. "I should remove extra blankets from my baby's crib." D. "I should place my baby's crib next to the heater to keep him warm during the winter."

Correct Answer is C

Explanation

A. "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps. Placing pads, pillows, or any soft bedding in a crib increases the risk of suffocation and sudden infant death syndrome (SIDS). The American Academy of Pediatrics (AAP) recommends a firm mattress with a tight-fitting sheet and no additional padding for infant safety.

B. "I will place my baby on his stomach when he is sleeping." Placing a baby on their stomach to sleep significantly increases the risk of SIDS. The safest sleep position for all infants is on their back, as this reduces the risk of airway obstruction and suffocation.

C. "I should remove extra blankets from my baby's crib." This statement shows correct understanding of safe sleep practices. Loose blankets and soft bedding pose a serious risk for SIDS and suffocation. Instead, parents are encouraged to use sleep sacks or wearable blankets to keep the baby warm without loose items in the crib.

D. "I should place my baby's crib next to the heater to keep him warm during the winter." Placing a crib near a heater or direct heat source can lead to overheating, which is a known risk factor for SIDS. It's important to maintain a moderate room temperature and avoid direct heat exposure to ensure the infant's safety and comfort.

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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

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Correct Answer is C

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