A nurse manager is revising a policy in the maternal unit to ensure proper identification of newborns. What should the nurse include in the policy?

Check the newborn’s identification using the crib card.

Require visitors to wear an identification band.

Replace the infant’s identification band after his name has been recorded.

Obtain an imprint of the infant’s feet prior to taking him to the nursery.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Checking the newborn’s identification using the crib card is not the most reliable method. The crib card could be misplaced or switched accidentally.
Choice B rationale
Requiring visitors to wear an identification band does not directly ensure the proper identification of newborns. While it can enhance the security of the unit, it does not link the newborn to their correct parents.
Choice C rationale
Replacing the infant’s identification band after his name has been recorded is not the most effective method. The identification band should be placed on the newborn immediately after birth to prevent mix-ups.

Choice D rationale
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is the correct answer. This method is a reliable way to identify newborns. The footprints, along with the mother’s fingerprints, are often taken within the first hour after birth. This can be used for identification throughout the hospital stay.

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Correct Answer is B

Explanation

Choice A rationale
Progressive sacral discomfort during contractions is a normal part of labor and does not necessarily require reassessment.
Choice B rationale
An urge to have a bowel movement during contractions could indicate that the baby’s head is descending into the birth canal. This could signal that the labor is progressing more quickly than expected, and the nurse should reassess the client.
Choice C rationale
Intense contractions lasting 45 to 60 seconds are a normal part of active labor and do not necessarily require reassessment.

Choice D rationale
A sense of excitement and warm, flushed skin are normal emotional and physiological responses to labor and do not necessarily require reassessment.

A. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client B. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period C. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period D. Three fetal movements perceived by the client in a 20-min testing period

Correct Answer is A

Explanation

Choice A rationale
Irregular contractions of 10 to 20 seconds in duration that are not felt by the client during a nonstress test may indicate a need for further diagnostic testing. These could be Braxton Hicks contractions, which are normal, but if they become regular and increase in intensity, they could indicate preterm labor.
Choice B rationale
An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal finding on a nonstress test. This is known as a reactive nonstress test and indicates that the fetus is well-oxygenated.
Choice C rationale
No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period is a normal finding on a nonstress test. Late decelerations can indicate fetal hypoxia.
Choice D rationale
Three fetal movements perceived by the client in a 20-min testing period is a normal finding on a nonstress test. Fetal movement is a positive sign of fetal well-being.

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A nurse manager is revising a policy in the maternal unit to ensure proper identification of newborns. What should the nurse include in the policy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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