A nurse is caring for a new mother who is worried about her newborn’s crossed eyes. What is a therapeutic response from the nurse?
I will inform your primary care provider about your concerns.
This happens because newborns lack muscle control to regulate eye movement.
I will take your baby to the nursery for further examination.
This is a concern, but strabismus can be easily treated with patching.
The Correct Answer is B
Choice A rationale
While it’s important to communicate any concerns to the primary care provider, this response does not provide immediate reassurance or information to the mother about her newborn’s crossed eyes.
Choice B rationale
This is the most therapeutic response. It provides factual information that can reassure the mother. Newborns often lack the muscle control to regulate eye movement, which can result in temporary crossing of the eyes.
Choice C rationale
Taking the baby to the nursery for further examination may cause unnecessary worry for the mother. It’s better to provide reassurance and education first.
Choice D rationale
This response may cause unnecessary worry for the mother. Strabismus, or constant misalignment of the eyes, is not typically seen in newborns and would require treatment. However, temporary crossing of the eyes due to lack of muscle control is normal. Propranolol Propranolol Explore
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Encouraging self-care is important, but it may not be the immediate priority if the patient is exhibiting manic behavior and has recently experienced significant personal stressors.
Choice B rationale
Assisting the patient in identifying coping behaviors is a key part of treatment, but it may not be the immediate priority if the patient is at risk of self-harm.
Choice C rationale
Preventing self-directed violence is the priority action. Patients exhibiting manic behavior may have impaired judgment and impulse control, putting them at risk of self-harm.
Choice D rationale
Identifying support systems is important, but it may not be the immediate priority if the patient is at risk of self-harm.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
While monitoring abdominal girth can be important in patients with cirrhosis, especially those with ascites, it is not typically an assessment finding that requires immediate follow-up.
Choice B rationale
A blood pressure of 82/58 mm Hg is low and could indicate hypotension, which requires immediate follow-up.
Choice C rationale
A heart rate of 101/min is elevated and could indicate tachycardia, which requires immediate follow-up.
Choice D rationale
An oxygen saturation of 92% is lower than the normal range of 95% to 100%, indicating potential hypoxia, which requires immediate follow-up.
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