A nurse is reviewing the safety plan for preventing newborn abduction with newly licensed nurses. Which of the following information should the nurse include in the teaching?
Instruct the client to carry the newborn in their arms when going to the nursery.
Remove the electronic security sensor when the newborn is in the client's room.
Apply identification bands after the newborn's first bath.
Discourage family from posting photos of the newborn on social media.
The Correct Answer is D
Rationale:
A. Instruct the client to carry the newborn in their arms when going to the nursery: Carrying a newborn to the nursery without security measures increases the risk of abduction. Infants should always be transported in a secure bassinet or by authorized staff using the hospital’s safety protocols.
B. Remove the electronic security sensor when the newborn is in the client's room: The electronic security sensor is essential for monitoring the newborn’s location within the hospital. Removing it defeats the purpose of the abduction prevention system and is unsafe.
C. Apply identification bands after the newborn's first bath: Identification bands should be applied immediately after birth to ensure accurate identification from the start. Waiting until after the first bath delays verification and increases risk for misidentification or abduction.
D. Discourage family from posting photos of the newborn on social media: Sharing identifiable information or images online can inadvertently alert potential abductors to the newborn’s presence. Families should be advised to limit social media exposure until the infant’s safety can be ensured.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","F"]
Explanation
Rationale:
A. Monitor the height and tone of the client's fundus: Assessing uterine fundus is essential postpartum, especially with signs of infection and moderate lochia. Monitoring for firmness, height, and consistency helps identify uterine atony or worsening infection, guiding timely interventions to prevent hemorrhage or complications.
B. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics prescribed for postpartum infections, such as clindamycin, are considered compatible with breastfeeding. Advising formula feeding unnecessarily could disrupt breastfeeding without clinical justification.
C. Initiate contact precautions: Postpartum infections like endometritis or mastitis are generally not spread via contact in a hospital setting. Standard precautions, including hand hygiene, are sufficient unless a specific transmissible pathogen is identified.
D. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene prevents the spread of infection and reduces the risk of secondary infections. Teaching proper handwashing is an essential standard precaution for clients with postpartum infections.
E. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: Routine cultures of lochia are not indicated unless there is suspicion of an unusual pathogen or worsening infection. Assessment and empiric antibiotics are standard for postpartum endometritis based on clinical findings.
F. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes uterine drainage, reduces stasis of lochia, and supports comfort. This position aids in preventing complications such as uterine infection or retention of lochia.
G. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor. It is not indicated for postpartum infection, uterine atony, or lochia management and is not appropriate in this scenario.
Correct Answer is ["C","D","E"]
Explanation
Rationale for correct choices
• Right lower extremity +2 edema from ankle to below knee: This level of edema in one limb suggests impaired venous return and is a key indicator of possible deep vein thrombosis. Unilateral swelling that develops with reduced mobility places the client at higher risk and warrants immediate assessment. Early detection is important to prevent progression to pulmonary embolism.
• Skin warm and inflamed on right lower extremity: Localized warmth and inflammation are hallmark findings of venous thrombosis or inflammatory processes in the limb. The client’s sedentary pattern and unilateral symptoms strengthen the suspicion of a vascular complication. Prompt evaluation helps guide diagnostic testing such as Doppler ultrasound.
• Slight limp with weight bearing on right extremity: A new limp combined with swelling and inflammation suggests evolving pain or functional impairment. This may indicate deep venous obstruction, localized inflammation, or injury exacerbated by reduced mobility.
Rationale for incorrect choices
• Client is awake, alert, oriented x3: This indicates intact neurological status and does not require follow-up at this time. The client shows no evidence of cognitive changes, syncope, or neurological compromise.
• Client reports no palpitations, heart rhythm regular: A regular heart rhythm without palpitations suggests stable cardiovascular status. There are no immediate arrhythmia-related concerns requiring follow-up.
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