A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

"Have you tried holding your infant skin-to-skin?"

"is your infant able to latch on during breastfeeding?"

"What is your infant's level of activity?"

"Have you considered joining a parents' support group?"

Answer and Explanation

The Correct Answer is B

A) "Have you tried holding your infant skin-to-skin?":

While skin-to-skin contact can be beneficial for infant bonding and comfort, the priority for a postoperative infant following a cleft palate repair is to ensure adequate feeding. While skin-to-skin contact can promote bonding and provide comfort, it does not directly address the infant's ability to latch on during breastfeeding, which is crucial for nutritional intake and healing postoperatively.

B) "Is your infant able to latch on during breastfeeding?":

This question addresses the priority concern for the nurse, which is the infant's ability to effectively latch on during breastfeeding. Adequate latch is essential for proper nutrition and hydration, especially for an infant recovering from a cleft palate repair surgery. The nurse needs to assess whether the infant can latch on properly to ensure adequate feeding and support optimal healing.

C) "What is your infant's level of activity?":

While assessing the infant's level of activity is important for overall health and well-being, it is not the priority question in this scenario. The nurse's primary focus should be on assessing the infant's feeding ability and ensuring adequate nutritional intake postoperatively.

D) "Have you considered joining a parents' support group?":

Joining a parents' support group can be valuable for emotional support and sharing experiences, but it is not the priority question in this situation. The immediate concern is ensuring the infant's nutritional needs are being met, particularly in the context of breastfeeding challenges following cleft palate repair surgery.

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Correct Answer is A

Explanation

A) ADL (Activities of Daily Living): This abbreviation is commonly used in healthcare documentation to refer to the routine tasks individuals perform independently for self-care, such as bathing, dressing, grooming, and toileting. Reminding the newly licensed nurse to use the abbreviation ADL ensures clear and concise documentation of the client's functional status and care needs.

B) SQ: While SQ could stand for subcutaneous (as in SQ injection), it's generally recommended to use the full term "subcutaneous" in documentation to avoid confusion or misinterpretation. Using abbreviations like SQ can lead to errors or miscommunication in healthcare settings.

C) AU: This abbreviation typically stands for "each ear" when documenting information related to the ears, such as when administering eardrops or assessing for symptoms. However, similar to SQ, it's preferable to use the full term "each ear" in documentation to ensure clarity and avoid ambiguity.

D) HS: HS commonly stands for "hour of sleep" or "at bedtime" when documenting medication administration times. However, like other abbreviations, it's advisable to use the full term "at bedtime" to prevent misunderstandings or errors related to medication dosing schedules.

A. A newborn has an Apgar score of 7 at 5 min after birth. B. A newborn has respiratory distress and requires oxygen. C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth. D. A newborn receives a heel stick on the outer aspect of the heel.

Correct Answer is C

Explanation

Answer: C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth.

Rationale:

A. A newborn has an Apgar score of 7 at 5 min after birth:
An Apgar score of 7 is within the acceptable range and does not indicate an adverse event or require an incident report. This score reflects a newborn transitioning well to extrauterine life with only mild adjustments needed.

B. A newborn has respiratory distress and requires oxygen:
While respiratory distress requires prompt intervention, it can be an expected complication in some neonates. Administering oxygen in this context is an appropriate clinical response, not a reportable incident.

C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth:
Erythromycin should be administered within 1 to 2 hours after birth to prevent ophthalmia neonatorum. A 4-hour delay exceeds this timeframe and poses a potential risk to the infant’s health, qualifying as a deviation from standard protocol that warrants an incident report.

D. A newborn receives a heel stick on the outer aspect of the heel:
Performing a heel stick on the outer aspect of the heel is the correct location to avoid nerve and bone injury. This is a safe and standard practice and does not require an incident report.

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A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?

Correct Answer is A

Explanation

A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

Correct Answer is C

Explanation

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