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 A

Explanation

A. Hypotension: This is the correct answer. Hypotension, or low blood pressure, is a common side effect of epidural anesthesia. The epidural can block sympathetic nerves, which can cause blood vessels to dilate and lead to a drop in blood pressure.

B. Respiratory depression: While respiratory depression can occur with certain types of anesthesia, it is not a common side effect of epidural anesthesia.

C. Tachycardia: Tachycardia, or rapid heart rate, is not a typical side effect of epidural anesthesia.

D. Vomiting: Nausea and vomiting can occur with any type of anesthesia, but they are not specific to epidural anesthesia and are not the most common complication. Hypotension is a more common and significant complication that should be monitored for in a client who has had an epidural block.

A. Place the client in knee chest position B. Cover the cord with a sterile moist saline dressing C. Insert a gloved hand into the vagina to relieve pressure on the cord D. Prepare the client for an immediate birth.

Correct Answer is A

Explanation

A. Place the client in knee chest position: This is the correct answer. If the nurse observes a prolapsed umbilical cord (the cord coming out before the baby), the first action should be to position the mother to relieve pressure on the cord. The knee-chest position can help achieve this.

B. Cover the cord with a sterile moist saline dressing: This action is important but not the first thing the nurse should do. The priority is to relieve pressure on the cord to prevent cord compression and subsequent fetal hypoxia.

C. Insert a gloved hand into the vagina to relieve pressure on the cord: This action may be necessary in some cases, but it is not the first action. The initial response should be to change the mother’s position to relieve pressure on the cord.

D. Prepare the client for an immediate birth: While an immediate birth may be necessary in the case of a prolapsed umbilical cord, the first action should be to relieve pressure on the cord to prevent fetal hypoxia. Preparations for an immediate birth would follow after initial interventions.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is A

Explanation

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