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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Answer: (C) 4-0-1-2-2

Rationale:

A) 2-0-0-2-0: This option is incorrect because it does not accurately represent the client's pregnancy history. The GTPAL system includes:

G: Total number of pregnancies
T: Number of term deliveries (after 37 weeks)
P: Number of preterm deliveries (between 20 and 37 weeks)
A: Number of pregnancies ending in spontaneous or elective abortion (before 20 weeks)
L: Number of living children

For this client:

G: 4 (one current pregnancy, one abortion, and twins plus one more spontaneous abortion)
T: 0 (no deliveries at term)
P: 2 (twins born at 36 weeks and another preterm delivery)
A: 1 (one spontaneous abortion at 15 weeks)
L: 2 (living children from the twins)

B) 3-0-2-0-2: This option is incorrect because it does not account for the total number of pregnancies or the number of pregnancies ending in abortion accurately.

C) 4-0-1-2-2: This option is correct because it accurately represents the client's pregnancy history:

G (Gravida): 4 (including the current pregnancy and all past pregnancies)
T (Term deliveries): 0 (no deliveries at term)
P (Preterm deliveries): 2 (twins at 36 weeks and another preterm delivery)
A (Abortions): 1 (spontaneous abortion at 15 weeks)
L (Living children): 2 (twins)

D) 4-2-0-2-2: This option is incorrect because it misrepresents the number of term and preterm deliveries and does not account for the spontaneous abortion correctly.

A. Large amount of vaginal bleeding B. Severe nausea and vomiting C. Unilateral cramp-like abdominal pain D. Uterine enlargement greater than expected for gestational age

Correct Answer is C

Explanation

A. Large amount of vaginal bleeding: While vaginal bleeding can occur with an ectopic pregnancy, it is usually light and not typically a large amount.

B. Severe nausea and vomiting: These symptoms are common in normal pregnancies and are not specific to ectopic pregnancy.

C. Unilateral cramp-like abdominal pain: This is the correct answer. One of the most common symptoms of an ectopic pregnancy is sharp or cramp-like pain on one side of the lower abdomen. The pain usually starts on one side and may spread across the belly. It can be constant or come and go, and the pain can range from mild to severe.

D. Uterine enlargement greater than expected for gestational age: This is not typically associated with an ectopic pregnancy. In fact, the uterus may not enlarge as expected in an ectopic pregnancy because the embryo is not growing inside the uterus. Instead, the embryo is growing outside the uterus, most commonly in a fallopian tube.

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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?

Nursing Test Bank

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