A nurse is caring for a new mother who is worried about her newborn’s crossed eyes. Which of the following responses by the nurse would be therapeutic?

“I will call your primary care provider to report your concerns.”.

“This is a concern, but strabismus is easily treated with patching.”.

“This occurs because newborns lack muscle control to regulate eye movement.”.

“I will take your baby to the nursery for further examination.”. .

Answer and Explanation

The Correct Answer is C

Choice A rationale
While it’s important to report concerns to the primary care provider, this does not directly address the mother’s concern about her newborn’s crossed eyes.
Choice B rationale
Strabismus is a condition where the eyes do not properly align with each other, but it is not the same as the normal crossing of a newborn’s eyes.
Choice C rationale
This is the correct answer. Newborns often lack the muscle control to regulate eye movement, which can cause their eyes to cross.
Choice D rationale
Taking the baby to the nursery for further examination may be necessary if there are other concerns, but it does not directly address the mother’s concern about her newborn’s crossed eyes.

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Correct Answer is C

Explanation

The correct answer is choiceC. Respiratory rate.

Choice A rationale:

Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus.However, when administering magnesium sulfate, the primary concern is the mother’s respiratory status due to the risk of respiratory depression, which can be a side effect of the medication.

Choice B rationale:

While bowel sounds are an important part of a comprehensive assessment, they are not the primary concern when administering magnesium sulfate.Magnesium sulfate primarily affects the neuromuscular and respiratory systems.

Choice C rationale:

Respiratory rate is the primary nursing assessment for a client receiving magnesium sulfate IV.Magnesium sulfate can cause respiratory depression, so it is essential to monitor the client’s respiratory status closely to detect any signs of respiratory compromise early.

Choice D rationale:

Monitoring temperature is important in any clinical setting, but it is not the primary concern when administering magnesium sulfate.The primary focus should be on the respiratory rate due to the potential for respiratory depression.

A. “I will call my provider if I have discharge from my incision.”. B. “I am likely to have a fever during the first week I am home.”. C. “I will rest in a recliner until my incision is healed.”. D. “I should not have unrelieved pain in my abdomen.”.

Correct Answer is ["A","D"]

Explanation

Choice A rationale
The client understanding the importance of monitoring their incision for signs of infection, such as discharge, indicates effective teaching. It is crucial for the client to report any changes to their healthcare provider promptly.
Choice B rationale
Having a fever during the first week at home is not a normal postoperative symptom and could indicate an infection. Therefore, this statement does not indicate effective teaching.
Choice C rationale

Resting in a recliner until the incision is healed is not necessary. While it’s important for the client to rest and recover after surgery, they should also engage in light physical activity, such as walking, to promote circulation and prevent complications such as blood clots.
Choice D rationale
The client should not have unrelieved pain in their abdomen. Persistent pain could indicate a complication, such as an infection or a hematoma. Therefore, this statement indicates effective teaching.

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A nurse is caring for a new mother who is worried about her newborn’s crossed eyes. Which of the following responses by the nurse would be therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer magnesium sulfate IV to a client who is in labor. Which of the following is the primary nursing assessment for this client?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply)

Correct Answer is ["A","D"]

Explanation

While evaluating an external monitor tracing of a woman in active labor, the nurse observes that the FHR begins to decelerate late in the contraction, with the decelerations occurring after the peak of the contraction. What is the nurse’s first priority?

A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do if her newborn is persistently crying. Which of the following strategies should the nurse suggest? (Select all that apply.)

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