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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Breast engorgement typically occurs around days 3 to 5 postpartum, so encouraging frequent nursing at 14 hours postpartum will not impact milk production at this stage.
B. A temperature of 37.7°C (100°F) is a normal postpartum finding due to dehydration and hormonal changes. It does not require reporting unless it exceeds 38°C (100.4°F).
C. Increasing IV fluids is not necessary unless there is evidence of dehydration or another medical indication.
D. A slightly deviated fundus suggests bladder distension, which can interfere with uterine involution. Asking the client to empty her bladder helps the uterus contract properly and prevents complications such as postpartum hemorrhage.
Correct Answer is B
Explanation
Choice A rationale: The Mongolian spot is a bluish-gray birthmark that is often seen on the lower back or buttocks of newborns with darker skin tones. It is not related to the swelling described in the scenario.
Choice B rationale: Caput succedaneum is a common condition in newborns delivered by vacuum extraction. It is characterized by swelling of the soft tissues of the scalp that crosses the suture lines. The swelling occurs due to pressure from the vacuum extractor during delivery and is caused by fluid accumulation between the scalp and the skull. Caput succedaneum is typically a benign and self-resolving condition that does not require treatment.
Choice C rationale: Cephalhematoma is a collection of blood between the periosteum and the skull bone. Unlike caput succedaneum, it does not cross the suture lines and can take weeks to months to resolve.
Choice D rationale: Erythema toxicum is a common skin rash in newborns characterized by red or pink spots with a yellow or white bump in the center. It is not related to the swelling described in the scenario.
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