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 B

Explanation

A. The client requires a rubella vaccination at this time: This is not correct. Rubella vaccination is contraindicated during pregnancy because it is a live virus vaccine.

B. The client requires a rubella immunization following delivery: This is the correct answer. A negative rubella titer indicates that the client is not immune to rubella, meaning she has not been vaccinated or has not had the disease. Therefore, she should be vaccinated after delivery to prevent future infection.

C. The client is immune to the rubella virus: This is not correct. A negative rubella titer indicates that the client is not immune to rubella.

D. The client is not experiencing a rubella infection at this time: This is not necessarily correct. A negative rubella titer indicates lack of immunity, not whether or not the client is currently infected. If rubella infection is suspected, specific tests for the virus would need to be done.

A. Encourage the client to empty her bladder every 2 hr. B. Remind the client to bear down with each contraction. C. Maintain the client in the lithotomy position. D. Perform vaginal examinations frequently.

Correct Answer is A

Explanation

A. Encourage the client to empty her bladder every 2 hr.: This is the correct choice. A full bladder can impede the descent of the fetus and can increase the client’s discomfort. Therefore, it’s important to encourage the client to empty her bladder regularly.
B. Remind the client to bear down with each contraction: This is not recommended during the active phase of the first stage of labor. The client should be instructed to bear down only during the second stage of labor when the cervix is fully dilated.
C. Maintain the client in the lithotomy position: This is not necessary during the active phase of the first stage of labor. The lithotomy position is typically used during the second stage of labor for the actual delivery of the baby. During the first stage, the client should be encouraged to find a comfortable position.
D. Perform vaginal examinations frequently: This is not recommended. Frequent vaginal examinations increase the risk of introducing infection. Vaginal examinations should be performed only when necessary to assess the progress of labor.

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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

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following indicates the correct interpretation of this data?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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