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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Large amount of vaginal bleeding: While vaginal bleeding can occur with an ectopic pregnancy, it is usually light and not typically a large amount.
B. Severe nausea and vomiting: These symptoms are common in normal pregnancies and are not specific to ectopic pregnancy.
C. Unilateral cramp-like abdominal pain: This is the correct answer. One of the most common symptoms of an ectopic pregnancy is sharp or cramp-like pain on one side of the lower abdomen. The pain usually starts on one side and may spread across the belly. It can be constant or come and go, and the pain can range from mild to severe.
D. Uterine enlargement greater than expected for gestational age: This is not typically associated with an ectopic pregnancy. In fact, the uterus may not enlarge as expected in an ectopic pregnancy because the embryo is not growing inside the uterus. Instead, the embryo is growing outside the uterus, most commonly in a fallopian tube.
Correct Answer is C
Explanation
A. Assist the client into a comfortable position: While comfort is important during labor, it is not the priority in this situation. The client is not yet fully dilated and should not start pushing yet.
B. Help the client to the bathroom to void: This is not the priority at this time. The client is in active labor and should not be moved unnecessarily.
C. Have the client pant during the next contractions: This is the correct answer. Panting can help to resist the urge to push until the cervix is fully dilated to 10 cm. Pushing before full dilation can lead to cervical edema and prolong the labor process.
D. Observe the perineum for signs of crowning: While this will be important as the client gets closer to delivery, it is not the priority at this time. The client is not yet fully dilated and should not start pushing yet.
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