A nurse is providing teaching about newborn care to a client who is 2 hr postpartum.
Which of the following statements by the client indicates a need for further teaching?
"I should keep my baby's head covered.”
"My baby's bassinet should be kept away from fans and air conditioning.”
"My baby's temperature will be checked rectally every hour.”
"I should place my baby on my stomach and cover her with a warm blanket.”
The Correct Answer is C
The correct answer is choice C.
Choice A rationale:
Keeping the baby’s head covered helps to prevent heat loss, as newborns lose a significant amount of heat through their heads.
Choice B rationale:
Keeping the baby’s bassinet away from fans and air conditioning helps to maintain a stable body temperature.
Choice C rationale:
Newborns’ temperatures are typically checked every 3 to 4 hours, not every hour, and are usually done axillary, not rectally.
Choice D rationale:
Placing the baby on the mother’s stomach and covering her with a warm blanket promotes skin-to-skin contact and helps to maintain the baby’s body temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale:
An internal examination could disturb the placenta and cause profound bleeding, which is a life-threatening condition for both the mother and the fetus.
Choice B rationale:
While there is always a risk of introducing infection during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.
Choice C rationale:
An internal examination could potentially initiate preterm labor, but this is not the primary concern with placenta previa.
Choice D rationale:
While there is a risk of rupture of the amniotic membranes during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Superficial structures above the muscle refer to first-degree lacerations, which only involve the skin of the perineum and vaginal mucosa.
Choice B rationale:
A fourth-degree laceration does not stop at the anterior rectal wall. It extends through the anal sphincter and into the rectal mucosa.
Choice C rationale:
While a fourth-degree laceration does involve the anal sphincter muscle, it also includes the underlying rectal mucosa.
Choice D rationale:
A fourth-degree laceration involves the perineal muscles, the anal sphincter, and the underlying rectal mucosa.
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