A home health nurse is caring for a newborn.
Click to highlight the findings that require further intervention. To deselect a finding, clock on the finding again.
Nurses' Notes
3 weeks old:
Follow up newborn weight check. Parent is smoking a cigarette in the living room while infant sleeps. Parent reports the newborn is breastfeeding well. The newborn is asleep in their bassinet in the living room. Newborn currently asleep in prone position. Parent reports that the newborn sleeps in their bassinet in the parents' bedroom overnight.
Vital Signs
3 weeks old:
- Temperature 36.9° C (98.4" F)
- Heart rate 138/min
- Respiratory rate 42/min
Parent is smoking a cigarette in the living room while infant sleeps.
Newborn currently asleep in prone position.
Parent reports that the newborn sleeps in their bassinet in the parents' bedroom overnight.
Temperature 36.9° C (98.4° F)
Heart rate 138/min
Respiratory rate 42/min
The Correct Answer is ["A","B"]
Rationale for Correct Findings:
-
Parent smoking around the infant exposes the newborn to secondhand smoke, increasing the risk of respiratory infections and sudden infant death syndrome (SIDS). Smoking should be avoided in the infant’s environment.
-
The prone sleeping position raises the risk of SIDS; current guidelines recommend placing infants to sleep on their backs (supine position) to reduce this risk.
Rationale for Incorrect Findings:
-
The newborn’s vital signs are within normal limits for a 3-week-old: temperature 36.9° C (98.4° F), heart rate 138/min, respiratory rate 42/min. These values indicate stable cardiopulmonary status and do not require intervention.
-
The newborn sleeping in a bassinet, particularly in the parents’ bedroom, follows safe sleep recommendations that reduce SIDS risk by promoting a separate, firm sleeping surface close to caregivers. This is an appropriate practice and does not require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Oropharyngeal suctioning may be necessary if secretions are causing distress, but it can also be uncomfortable and should be used cautiously.
Choice B reason: Turning the client can help manage noisy breathing by allowing secretions to drain and is a non- invasive comfort measure.
Choice C reason: Antiemetics are used to manage nausea and vomiting, not noisy breathing.
Choice D reason: An indwelling urinary catheter may be considered for comfort if the client cannot use the bathroom, but it does not address noisy breathing.
Correct Answer is C
Explanation
Choice A reason: Immunization clinics are typically considered a form of primary prevention, as they aim to prevent diseases before they occur.
Choice B reason: Smoking cessation classes are more aligned with tertiary prevention, focusing on individuals who already have a health issue (smoking) and are trying to prevent further complications or progression of disease.
Choice C reason: Scoliosis screenings are a form of secondary prevention. They are designed to detect scoliosis early in school-age children, which can then be managed before the condition worsens.
Choice D reason: Support groups are generally a part of tertiary prevention, providing support to individuals who are already affected by a health issue to help manage their condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.