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 A
Explanation
Choice A rationale: Weight loss in the first few days after birth is normal for newborns, and a weight loss of up to 7-10% of the birth weight is considered within the expected range. A 6% weight loss is within normal limits, and it is reassuring to inform the mother that this is typical.
Choice B rationale: Suggesting switching to formula is not necessary based on the weight loss described. Breastfeeding provides adequate nutrition for most newborns, and early weight loss is typical and not a cause for alarm.
Choice C rationale: While it is true that new mothers may worry about breastfeeding and milk supply, this response does not address the specific weight loss concern and might not fully reassure the mother.
Choice D rationale: A 6% weight loss is within the expected range for a newborn and does not warrant hospitalization. It is a normal finding, and most newborns will start to regain their birth weight within a few days of life.
Correct Answer is D
Explanation
Choice A rationale:
Uterine enlargement greater than expected for gestational age is not a typical finding in a possible ectopic pregnancy. An ectopic pregnancy occurs when the fertilized egg implants outside the uterus, usually in the fallopian tube, and the uterus does not enlarge normally.
Choice B rationale:
Copious vaginal bleeding is not a typical finding in a possible ectopic pregnancy. Vaginal bleeding can occur, but it is not usually copious.
Choice C rationale:
Severe nausea and vomiting are not typically associated with a possible ectopic pregnancy. Nausea and vomiting are common symptoms in early pregnancy, but they are not specific to an ectopic pregnancy.
Choice D rationale:
Pelvic pain is a common finding in a possible ectopic pregnancy. The pain is often sharp, and unilateral, and may be located on one side of the lower abdomen or pelvis.
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