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 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.
Correct Answer is B
Explanation
A. The client requires a rubella vaccination at this time: This is not correct. Rubella vaccination is contraindicated during pregnancy because it is a live virus vaccine.
B. The client requires a rubella immunization following delivery: This is the correct answer. A negative rubella titer indicates that the client is not immune to rubella, meaning she has not been vaccinated or has not had the disease. Therefore, she should be vaccinated after delivery to prevent future infection.
C. The client is immune to the rubella virus: This is not correct. A negative rubella titer indicates that the client is not immune to rubella.
D. The client is not experiencing a rubella infection at this time: This is not necessarily correct. A negative rubella titer indicates lack of immunity, not whether or not the client is currently infected. If rubella infection is suspected, specific tests for the virus would need to be done.
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