A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

Holding the newborn in an en face position

Asking the father to change the newborn's diaper

Viewing the newborn's actions to be uncooperative

Requesting the nurse take the newborn to the nursery so she can rest

Answer and Explanation

The Correct Answer is C

A. Holding the newborn in an en face position: This action promotes bonding between the mother and the newborn and is a positive interaction.

B. Asking the father to change the newborn's diaper: Involving the father in caregiving tasks fosters family involvement and bonding.

C. Viewing the newborn's actions to be uncooperative: This suggests a negative perception of the newborn's behavior, which could indicate potential issues with bonding or misunderstanding

infant cues, requiring the nurse's intervention.

D. Requesting the nurse take the newborn to the nursery so she can rest: While rest is important for the mother, separating the newborn from the mother could disrupt bonding and breastfeeding, so this action should be discussed further with the client to explore other options.

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Correct Answer is D

Explanation

A. A head circumference 1 cm greater than the chest is within normal variations and does not typically require immediate notification.

B. A positive Babinski reflex is a normal finding in newborns and does not warrant immediate notification.

C. Passage of meconium stool within the first 24 hours of life is considered normal and does not require notification.

D. The pinna (ear) below the outer canthus of the eye can indicate a condition called low-set ears, which may be associated with genetic syndromes or other abnormalities. This finding warrants notification to the provider for further evaluation.

A. A child who has a forehead wound that is bleeding copiously B. A child who has a compound fracture of the femur and is crying in pain C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip

Correct Answer is C

Explanation

A. A child who has a forehead wound that is bleeding copiously: While bleeding wounds require attention, they are not immediately life-threatening compared to other injuries described.

B. A child who has a compound fracture of the femur and is crying in pain: While painful, a

femur fracture is not typically immediately life-threatening unless it is causing severe bleeding or compromising circulation.

C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake:

These symptoms suggest potential head trauma and require urgent evaluation to assess for intracranial injuries.

D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip: These injuries, while concerning, are not immediately life-threatening compared to the potential head injury described in option C.

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A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

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Naxlex Comprehensive Predictor Exams

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