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. Discontinue the medication infusion: This is the correct choice. The client’s symptoms (respiratory rate of 10/min and absent deep-tendon reflexes) suggest magnesium toxicity, a serious complication of magnesium sulfate therapy. The nurse should immediately discontinue the medication infusion.

B. Place the client in Trendelenburg position: This is not the appropriate action. The Trendelenburg position is not used to treat magnesium toxicity.

C. Prepare for an emergency cesarean birth: This is not the appropriate action based on the given symptoms. While severe preeclampsia can sometimes necessitate an emergency cesarean birth, the symptoms described here are indicative of magnesium toxicity, not a need for immediate delivery.

D. Assess maternal blood glucose: This is not the appropriate action. While it’s important to monitor blood glucose levels in pregnant clients, especially those with gestational diabetes, the symptoms described here are indicative of magnesium toxicity, not hypoglycemia or hyperglycemia. Therefore, assessing blood glucose would not be the priority action.

A. Respiratory depression B. Drowsiness C. Nausea D. Facial flushing

Correct Answer is A

Explanation

A. Respiratory depression: This is the correct choice. Magnesium sulfate can depress the central nervous system, which can lead to respiratory depression. This is a serious side effect and should be reported to the provider immediately.

B. Drowsiness: While drowsiness can occur with magnesium sulfate use, it is not typically a sign of toxicity. However, if drowsiness is severe or accompanied by other symptoms, it should be reported to the provider.

C. Nausea: Nausea can occur with magnesium sulfate use, but it is not typically a sign of toxicity. However, if nausea is severe or accompanied by other symptoms, it should be reported to the provider.

D. Facial flushing: Facial flushing can occur with magnesium sulfate use, but it is not typically a sign of toxicity. However, if facial flushing is severe or accompanied by other symptoms, it should be reported to the provider.

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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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Correct Answer is A

Explanation

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