A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

“Look at how she looks as you when you speak. That’s a good sign.”

“We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.”

“There is no need to worry about that. Most forms of hearing loss are not inherited.”

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

Answer and Explanation

The Correct Answer is B

A.   While visual attention to the speaker is a positive sign, routine hearing screenings provide a more accurate assessment of hearing.
B.   Routine hearing screenings are conducted on newborns to identify hearing issues early, allowing for intervention if necessary.
C. While most forms of hearing loss may not be inherited, it's important to assess the newborn's hearing through appropriate screenings.
D.   Startle reflex is not a reliable indicator of hearing ability, and routine screenings provide more accurate information.

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Correct Answer is B

Explanation

A. Confirming that the newborn is at least 24 hours old is not a requirement for administering the HBV vaccine. The vaccine can be given to newborns shortly after birth, typically within 12 hours.
B. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration is correct. This needle size is appropriate for administering vaccines intramuscularly to newborns.
C. Assessing the dorsogluteal muscle as the preferred site for injection is incorrect; the ventrogluteal or vastus lateralis muscles are recommended for intramuscular injections in infants. The dorsogluteal site is not preferred for young children due to the risk of sciatic nerve injury.
D. Confirming that the newborn's mother has been infected with the HBV is not necessary for administering the vaccine, although if the mother is infected, the newborn should receive the HBV vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours of birth.

A. Allow the newborn to continue crying. B. Keep the newborn in the center of a large crib. C. Carry the newborn evert time he/she cries. D. Swaddle the newborn in a receiving blanket.

Correct Answer is D

Explanation

A. Allowing the newborn to continue crying without attempting to soothe the baby is not an appropriate strategy for responsive parenting.
B. Keeping the newborn in the center of a large crib without attending to the baby's needs is not responsive caregiving.
C. Carrying the newborn every time he/she cries may not be practical or necessary, and it's important to encourage safe sleep practices.
D. Swaddling the newborn in a receiving blanket can provide comfort and a sense of security, promoting sleep and reducing crying.

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A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

Nursing Test Bank

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Correct Answer is B

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Correct Answer is D

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