A home health nurse is caring for a newborn
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.
Parent reports the newborn is breastfeeding well.
Newborn currently asleep in prone position.
Heart rate 138/min
The Correct Answer is ["A","C"]
Rationale
- Parent is smoking a cigarette in the living room while infant sleeps: Secondhand smoke increases the newborn’s risk for sudden infant death syndrome (SIDS), respiratory infections, and asthma. Infants should not be in an environment where smoking occurs, especially while sleeping. The nurse should provide education and interventions to reduce smoke exposure and promote a safe sleep environment.
- Newborn currently asleep in prone position: Placing a newborn in the prone position to sleep significantly increases the risk of SIDS. The American Academy of Pediatrics recommends that infants sleep on their backs on a firm, flat surface with no soft bedding or objects. The nurse should educate the parent about safe sleep practices and reposition the infant to a supine position for all sleep periods.
- The newborn breastfeeding well is not a finding requiring further intervention because it indicates the infant is feeding adequately and having sufficient wet and dirty diapers, which are signs of good hydration and nutrition.
- Heart rate 138/min. This heart rate is normal for newborns whose normal range is 120-160bpm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Ginger is not an established treatment for allergic reactions. Allergic symptoms, such as sneezing, itching, or hives, are typically managed with pharmacologic interventions (e.g., antihistamines, corticosteroids) and avoidance of triggers. There is no clinical evidence that ginger reduces the immunologic response that causes allergies. Therefore, improvement in allergy symptoms would not indicate effectiveness of ginger therapy.
B. Menopausal symptoms, including hot flashes, night sweats, and mood changes, are sometimes managed with herbal therapies like black cohosh, red clover, or soy isoflavones. Ginger is not widely supported by research as an effective intervention for menopause. Therefore, a decrease in menopausal symptoms would not reliably indicate the effectiveness of ginger.
C. Ginger has well-documented antiemetic properties. It has been shown to be effective in reducing nausea and vomiting related to: Pregnancy (morning sickness), Motion sickness, Postoperative nausea and vomiting and chemotherapy-induced nausea. Its mechanism involves blocking serotonin receptors in the gastrointestinal tract and central nervous system, which helps reduce nausea signals. Therefore, a client reporting decreased nausea after using ginger directly demonstrates the intended therapeutic effect of the treatment, making this the correct indicator of effectiveness.
D. Eczema is a chronic inflammatory skin condition caused by genetic, environmental, and immune factors. Standard treatment includes moisturizers, topical corticosteroids, and avoidance of triggers. Ginger does not have documented anti-inflammatory effects sufficient to treat eczema. Improvement in eczema would not be attributed to ginger use.
Correct Answer is B
Explanation
Rationale:
A. Dandruff shampoo does not kill lice or nits effectively. High heat from a hair dryer is not a reliable or recommended method for lice eradication and may cause burns or scalp irritation.
B. This is a natural remedy sometimes used to suffocate lice. It is applied generously to the hair and scalp, covered with a shower cap for several hours, and then washed out. While not as consistently effective as pediculicides, it aligns with the guardian’s preference for nonchemical, natural treatment.
C. While cleaning personal items is important to prevent reinfestation, this action alone does not treat the lice on the child’s scalp. It is a supportive measure rather than a primary treatment.
D. Combing with a fine-tooth (nit) comb is an effective adjunctive method, especially after treatment, but it is time-consuming and typically used in combination with another treatment. It may not be sufficient alone to eliminate lice entirely.
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