A nurse is caring for a client who is postpartum. The client states, "I am concerned about my baby's hearing because my mother was born deaf." Which of the following statements should the nurse make?

"The best way to determine if your baby can hear is to clap your hands loudly and see if she startles."

"There is no need to worry about that. Most forms of hearing loss are not Inherited."

"We do routine hearing screenings on newborns. You'll know the results before you leave the hospital."

"Look at how she looks as you when you speak. That's a good sign."

Answer and Explanation

The Correct Answer is C

Choice A rationale: This statement is not accurate, as startling in response to a loud noise does not necessarily indicate that the baby can hear normally. Startling can be a normal reflex response and may not accurately assess the baby's hearing ability.
Choice B rationale: While it is true that many forms of hearing loss are not inherited, the client's concern about her family history of deafness is valid. It is essential to address her concerns and provide appropriate information about the hearing screening.
Choice C rationale: Routine hearing screenings are typically performed on newborns to identify any potential hearing problems early on. Early detection and intervention for hearing loss can lead to better outcomes for the baby's language development and overall well-being. By reassuring the client about the hearing screening, the nurse addresses her concerns and provides information about the process.
Choice D rationale: While visual cues and responses are important for the baby's communication and bonding, they do not provide a definitive assessment of the baby's hearing ability. Hearing screening is a more reliable method to detect potential hearing problems in newborns.

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Correct Answer is B

Explanation

Choice A rationale:
Placing only part of the nipple in the baby's mouth may result in an ineffective latch, leading to breastfeeding difficulties.
Choice B rationale:
Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby’s mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness.
Choice C rationale:
Placing the entire areolar is not appropriate.
Choice D rationale:
While babies do have natural instincts to breastfeed, it is essential to provide the mother with specific guidance on achieving a proper latch to ensure successful breastfeeding.

A. When she does not desire future pregnancies B. Prior to discharge from the hospital after giving birth C. Two weeks before attempting pregnancy again D. Prior to giving birth

Correct Answer is B

Explanation

Choice A rationale: If the woman does not desire future pregnancies, she may not need the MMR vaccine, but the timing of vaccine administration is not appropriate for the current situation.
Choice B rationale: Administering the MMR vaccine prior to discharge from the hospital after giving birth is recommended during the postpartum period, especially if the woman is planning to have more children in the future.
Choice C rationale: The MMR vaccine contains live attenuated viruses and is contraindicated during pregnancy. If a woman is planning to become pregnant and is not immune to rubella, she should receive the MMR vaccine at least one month before attempting pregnancy. This allows time for her body to develop immunity before conception occurs.
Choice D rationale: The current guidelines from the Centers for Disease Control and Prevention (CDC) advise that the measles, mumps, rubella (MMR) vaccine should not be administered during pregnancy due to possible effects on the uterus.

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A nurse is caring for a client who is postpartum. The client states, "I am concerned about my baby's hearing because my mother was born deaf." Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about immunizations with a woman in her first trimester of pregnancy whose diagnostic testing indicates she does not have immunity to rubella. The nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at which of the following times?

Correct Answer is B

Explanation

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