A nurse is reinforcing teaching about safety measures for preventing newborn abduction with a client who is postpartum. Which of the following statements should the nurse make?

"Place your baby in the bassinet in your room by the bed when you use the bathroom."

"Make sure anyone caring for or transporting your baby is wearing an identification badge."

"Carry your baby in your arms when you go for a walk in the hallway."

"If your baby's identification band slips off place it in the drawer of the bassinet

Answer and Explanation

The Correct Answer is B

A)   Incorrect- While placing the baby in the bassinet in the room is a good practice, it may not be sufficient to prevent abduction.
B)   Correct - Ensuring that anyone caring for or transporting the baby is wearing an identification badge helps confirm their authorized status to handle the baby.
C)   Incorrect- Carrying the baby in the arms is a safe practice, but it doesn't specifically address preventing abduction.
D)   Incorrect- Placing the identification band in the bassinet drawer is not a recommended practice, as it can potentially lead to confusion or misidentification.

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Correct Answer is C

Explanation

A) Incorrect- A reddened area on the calf might indicate a potential blood clot (deep vein thrombosis), which is important to assess but may not be the highest priority.
B) Incorrect- Painful uterine contractions during breastfeeding can be a normal response due to oxytocin release during breastfeeding and might not require immediate reporting.
C) Correct - A urinary output of 125 mL in 4 hours is significantly low and could indicate inadequate fluid intake, potential urinary retention, or other issues that need prompt attention. It is a sign of impaired renal function. This could indicate dehydration, blood loss, infection, or kidney injury. The nurse should assess the client's fluid intake and output, vital signs, urine specific gravity, and serum electrolyte levels. The nurse should also monitor the client for signs of hypovolemia, such as tachycardia, hypotension, and decreased skin turgor.
D) Incorrect- Changing a perineal pad every 2 hours is within the normal range for postpartum bleeding and might not require immediate reporting.

A. Insert the needle at a 45° angle B. Obtain parental consent C. Give the first dose at 24 hr after birth. D. Administer the medication into the dorsal gluteal muscle

Correct Answer is C

Explanation

A) Incorrect- The angle of insertion for the hepatitis B vaccine is typically 90 degrees.

B) Incorrect- Obtaining parental consent is important for any medical procedure involving a minor, but it is not specific to the administration of the hepatitis B vaccine.
C) Correct - The first dose of the hepatitis B vaccine is usually given within the first 24 hours after birth to newborns whose mothers are hepatitis B positive to prevent vertical transmission.
D) Incorrect- The hepatitis B vaccine is usually administered into the vastus lateralis muscle in the newborn's thigh, not the dorsal gluteal muscle.

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A nurse is reinforcing teaching about safety measures for preventing newborn abduction with a client who is postpartum. Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

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