A nurse in the nursery is caring for a newborn.
The newborn’s grandmother asks if she can take the newborn to the mother’s room. What is an appropriate response by the nurse?

“Have the mother call and I will take the baby to the room.”.

“If you show me your photo identification, you can take the infant.”.

“You can push the baby to the room in a wheeled bassinet.”.

“You may carry your grandchild to the room.”. .

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A

Choice A rationale: Ensuring that the mother calls and the nurse takes the baby to the room maintains security and safety protocols. It prevents unauthorized individuals from handling the infant, thus minimizing the risk of abduction or harm.

Choice B rationale: Showing photo identification alone is not sufficient to ensure the safety of the newborn. The nurse should directly handle the transfer of the baby to maintain strict security measures and verify the proper identification in the process.

Choice C rationale: Allowing someone to push the baby in a wheeled bassinet without proper authorization and identification verification does not adhere to safety protocols. The nurse should always verify and manage the transfer to ensure the infant’s security.

Choice D rationale: Carrying the grandchild to the room without adequate identification verification and authorization does not follow safety protocols. The nurse should always be involved in the transfer to prevent any security breaches and ensure the infant’s safety.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The nurse should first: C. Administer additional morphine for pain management, followed by B. Reposition the client for comfort.

The client is reporting a pain level of 6 on a scale from 0 to 10, which indicates moderate to severe pain. As per the medication administration record, the client has an order for Morphine 4 mg IV bolus every 6 hours PRN for pain. Since the client is in pain, it would be appropriate to administer the morphine first to manage the pain.

After addressing the client’s pain, the nurse should then reposition the client for comfort. This can help to alleviate any discomfort or pressure points that may be contributing to the client’s pain. It’s also important to ensure the client’s safety and comfort by making sure the call light is within reach.

The options related to restraints (A and D for Response 1, and A, B, C, D for Response 2) are not relevant in this scenario as there is no indication in the provided information that the client is being restrained or that restraints are necessary. The client is drowsy but arouses easily to verbal stimuli and is able to follow simple commands, suggesting that they are not at risk of harming themselves or others, which would necessitate the use of restraints. Therefore, these options can be ruled out.

A. Lubricate the suction catheter tip with sterile saline B. Hyperventilate the patient on 100% oxygen prior to suctioning C. Perform chest physiotherapy prior to suctioning D. Suction two to three times with a 60-second pause between passes

Correct Answer is D

Explanation

Choice A rationale

Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.

Choice B rationale

Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.

Choice C rationale

Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.

Choice D rationale

Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.

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A nurse in the nursery is caring for a newborn. The newborn’s grandmother asks if she can take the newborn to the mother’s room. What is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

A nurse is performing tracheostomy care for a patient and plans to remove copious secretions. What actions should the nurse take?

Correct Answer is D

Explanation

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A nurse in the nursery is caring for a newborn.
The newborn’s grandmother asks if she can take the newborn to the mother’s room. What is an appropriate response by the nurse?