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 C

Explanation

A. Apply petroleum jelly to the cord stump: This is not recommended. Applying petroleum jelly can create a moist environment, which can delay the drying and falling off of the cord stump.
B. Wash the cord daily with mild soap and water: This is not necessary. The cord stump should be kept dry to promote healing and prevent infection. Washing it daily with soap and water can delay the drying process.
C. Give a sponge bath until the cord stump falls off: This is the correct choice. Sponge baths are recommended until the cord stump falls off and the area is healed. This helps to keep the cord stump dry and clean, which promotes healing and prevents infection.
D. Cover the cord with the diaper: This is not recommended. The diaper should be folded down so that the cord stump is exposed to air, which helps it dry out and fall off. Covering the cord stump with the diaper can keep it moist and delay the healing process. It can also expose the stump to urine and feces, which can lead to infection.

A. In about 10 days B. within 2 days C. In 6 to 8 days D. In 3 to 5 days

Correct Answer is D

Explanation

A. In about 10 days: This is not correct. Typically, the transition from colostrum to mature milk begins around 3 to 5 days after birth.
B. Within 2 days: This is not correct. While some women may notice changes in their breasts and the presence of colostrum within 2 days after birth, the transition to mature milk typically takes a bit longer.
C. In 6 to 8 days: This is not correct. While the exact timing can vary, most women will start to produce mature milk around 3 to 5 days after birth.
D. In 3 to 5 days: This is the correct choice. Most women will start to see their milk “come in,” or transition from colostrum to mature milk, around 3 to 5 days after birth. However, it’s important to note that this can vary from woman to woman. Some may experience this transition sooner, while others may experience it later. It’s always a good idea to consult with a healthcare provider or lactation consultant if there are any concerns about milk production or breastfeeding.

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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

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