A nurse is caring for a new mother who is concerned that her newborns eyes cross. Which of the following statements is a therapeutic response by the nurse?

This occurs because newborns lack muscle control to regulate eye movements

This is a concern, but strabismus is easily treated with patching

I will take your baby to the nursery for further examination

I will call your primary care provider to report your concerns

Answer and Explanation

The Correct Answer is A

A. “This occurs because newborns lack muscle control to regulate eye movements”: This is the correct answer. Newborns often have uncoordinated eye movements because the muscles that control their eyes are not fully developed yet. This is normal and usually resolves by the time the baby is about 3 months old.

B. “This is a concern, but strabismus is easily treated with patching”: This response is not entirely accurate. While strabismus can be treated with patching, it’s important to note that crossing of the eyes in newborns is usually normal and does not necessarily indicate strabismus.

C. “I will take your baby to the nursery for further examination”: This response may cause unnecessary worry for the mother. It’s better to reassure the mother that this is a normal occurrence in newborns.

D. “I will call your primary care provider to report your concerns”: This response may also cause unnecessary worry for the mother. The nurse should first reassure the mother that this is a normal occurrence in newborns.

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Correct Answer is ["A"]

Explanation

A. Cracked, peeling skin: This is correct. Postmature newborns have often lost the protective vernix caseosa, and their skin may be dry and cracked as a result.

B. Short soft fingernails: This is not correct. Postmature newborns often have long fingernails.

C. Primitive Moro reflexes: This is not correct. The Moro reflex is a normal reflex for newborns and is not specifically associated with post maturity.

D. Abundant lanugo: This is not correct. Lanugo, the fine hair that covers the body of the fetus, is usually shed before birth. Postmature newborns have often lost most of their lanugo.

E. Vernix caseosa: This is not correct. Vernix caseosa, the white, cheesy substance that covers the skin of the fetus, is usually lost before birth in postmature newborns. As a result, their skin may be dry and cracked.

A. Blood pressure 80/56 mm Hg B. Temperature 38.2°C (100.8") C. The client reports weakness of the low D. The client reports perfuse itching

Correct Answer is A

Explanation

A. Blood pressure 80/56 mm Hg: This is the correct answer. This blood pressure is low and could indicate hypotension, a common side effect of epidural analgesia. Hypotension can compromise both maternal and fetal circulation, making it the priority finding.

B. Temperature 38.2°C (100.8"): While this temperature is slightly elevated, it is not as immediately concerning as hypotension. The nurse should continue to monitor the client’s temperature and report any significant increases.

C. The client reports weakness of the low: If the client is reporting lower extremity weakness, this could be a side effect of the epidural analgesia. However, it is not as immediately concerning as hypotension.

D. The client reports perfuse itching: Itching can be a side effect of opioid medications. However, it is not as immediately concerning as hypotension. The nurse can report this to the provider and may be able to administer medication to relieve the itching if necessary.

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A nurse is caring for a new mother who is concerned that her newborns eyes cross. Which of the following statements is a therapeutic response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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