A nurse is caring for a new mother who is concerned that her newborns eyes cross. Which of the following statements is a therapeutic response by the nurse?
This occurs because newborns lack muscle control to regulate eye movements
This is a concern, but strabismus is easily treated with patching
I will take your baby to the nursery for further examination
I will call your primary care provider to report your concerns
The Correct Answer is A
A. “This occurs because newborns lack muscle control to regulate eye movements”: This is the correct answer. Newborns often have uncoordinated eye movements because the muscles that control their eyes are not fully developed yet. This is normal and usually resolves by the time the baby is about 3 months old.
B. “This is a concern, but strabismus is easily treated with patching”: This response is not entirely accurate. While strabismus can be treated with patching, it’s important to note that crossing of the eyes in newborns is usually normal and does not necessarily indicate strabismus.
C. “I will take your baby to the nursery for further examination”: This response may cause unnecessary worry for the mother. It’s better to reassure the mother that this is a normal occurrence in newborns.
D. “I will call your primary care provider to report your concerns”: This response may also cause unnecessary worry for the mother. The nurse should first reassure the mother that this is a normal occurrence in newborns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer oxygen using a non-rebreather mask: This action might be appropriate if the fetus shows signs of distress, but it’s not the first action the nurse should take. The first action should be to change the mother’s position to improve blood flow to the fetus.
B. Increase the rate of maintenance IV infusion: This action might be appropriate in some situations, but it’s not the first action the nurse should take. The first action should be to change the mother’s position to improve blood flow to the fetus.
C. Elevate the client’s legs: This action is not likely to improve the fetal heart rate pattern. The first action should be to change the mother’s position to improve blood flow to the fetus.
D. Place the client in the lateral position: This is the correct choice. The first action the nurse should take when noticing a deceleration in the fetal heart rate that occurs after the peak of the contraction (late decelerations) is to change the mother’s position. Placing the client in the lateral position can improve uteroplacental perfusion and may correct the problem. If the decelerations continue, further interventions such as administering oxygen or increasing IV fluids may be necessary.
Correct Answer is A
Explanation
A. Cullen’s sign: This is the correct choice. Cullen’s sign is a clinical sign in the abdomen characterized by bruising around the umbilicus. It indicates bleeding in the peritoneum.
B. Chadwick’s sign: This is not correct. Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. It is one of the physical signs of pregnancy.
C. Chvostek’s sign: This is not correct. Chvostek’s sign is a clinical sign for tetany in which the facial muscles twitch when the facial nerve is tapped. It is associated with hypocalcemia.
D. Goodell’s sign: This is not correct. Goodell’s sign is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascularization is a normal physiological response to pregnancy.
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