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 C
Explanation
Choice A rationale: Feeding a formula every 2 hours is not recommended and may lead to overfeeding. Newborns generally feed on demand, and the frequency of feeding can vary.
Choice B rationale: Breastfed newborns may have more frequent bowel movements, sometimes after each feeding. Two to three stools per day would be on the lower side of the normal range for breastfed infants.
Choice C rationale: Breastfeeding newborns typically need to feed frequently to establish a good milk supply and ensure adequate nutrition. Newborns often feed about 8 to 12 times in a 24-hour period, which translates to approximately five to seven times during the day and night.
Choice D rationale: Formula-fed newborns typically have more regular bowel movements compared to breastfed babies. Expecting only one stool every three days in a formula-fed newborn could indicate constipation, and it is not the expected norm.
Correct Answer is D
Explanation
Choice A rationale: Applying ice to the perineal area is not indicated in the case of suspected placenta previa. Placenta previa is related to the location of the placenta in the uterus and is not affected by the perineal area. Ice is commonly used for perineal discomfort after vaginal delivery but is not appropriate for placenta previa.
Choice B rationale: When a client is suspected to have placenta previa, a vaginal exam should be avoided because it can cause trauma to the placenta, leading to significant bleeding. Placenta previa is a condition where the placenta covers part or all of the cervix, and any disruption of the placenta can result in bleeding, which poses a risk to both the mother and the baby. Therefore, a vaginal exam is contraindicated in this situation.
Choice C rationale: Performing a rectal exam is also not appropriate for a client with suspected placenta previa. Rectal exams do not provide any relevant information about the placenta's location, and they can potentially cause discomfort or bleeding in this situation.
Choice D rationale: Applying an external fetal monitor is an appropriate action when caring for a pregnant client, regardless of whether there is a suspected placenta previa. The external fetal monitor is used to assess the baby's heart rate and uterine contractions and is a routine part of prenatal care. However, it does not specifically address the issue of placenta previa. The nurse should be vigilant for any signs of bleeding or changes in fetal heart rate pattern, which may indicate placental issues, and report them promptly for further evaluation and management.
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