A nurse is caring for a new mother who is concerned that her newborn has strabismus. Which of the following statements is a therapeutic response by the nurse?
"This is a concern, but strabismus is easily treated with patching."
"I will take your baby to the nursery for further examination."
"This occurs because newborns lack muscle control to regulate eye movement."
"I will call your primary care provider to report your concerns."
The Correct Answer is C
A. While strabismus may be treated with interventions such as patching, it is not always immediately concerning in newborns. The nurse should first provide accurate information about normal development.
B. Taking the baby to the nursery may not be necessary unless the child’s condition worsens or there is a
clear concern. A thorough assessment and explanation by the nurse are more appropriate.
C. Strabismus is common in newborns due to the immaturity of eye muscle control and usually resolves as the child develops. This is the most therapeutic response as it provides reassurance based on developmental norms.
D. Calling the primary care provider might be premature unless the nurse identifies a significant concern beyond normal development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Thickening the formula with cereal is generally not recommended for infants with a cleft lip and palate as it can cause additional feeding difficulties.
B. Positioning the infant laying back can increase the risk of aspiration and is not recommended. An upright position helps reduce the risk of aspiration.
C. Positioning the infant upright during feedings helps reduce the risk of aspiration and facilitates better feeding for infants with cleft lip and palate.
D. A nasogastric tube may be needed if the infant is unable to feed orally due to the severity of the cleft, but this is not a routine part of feeding education.
Correct Answer is A
Explanation
A. Pyloric stenosis typically causes projectile vomiting shortly after feedings. After vomiting, the infant may still appear hungry and may want to feed again. This is because the blockage prevents food from entering the small intestine, causing the infant to feel hungry soon after vomiting.
B. One of the classic physical findings of pyloric stenosis is a palpable "olive-shaped" mass in the upper abdomen, which is usually located in the right upper quadrant. This mass is the enlarged pyloric muscle.
C. Jelly-like stools are more characteristic of intussusception, not pyloric stenosis.
D. While the child may show signs of discomfort or irritability due to hunger, severe pain in the abdomen is not a hallmark of pyloric stenosis.
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