A nurse is reinforcing teaching with the parents of a newborn about bathing. Which of the following instructions should the nurse include in the teaching?
"Check the water temperature with your finger"
"Hold your baby under running water when washing his hair,"
"Cleanse the eyes from the inner canthus outward.
"Set the water heater to 125.6 degrees Fahrenheit."
The Correct Answer is C
A. "Check the water temperature with your finger": Checking water temperature with a finger is unreliable because fingers may tolerate higher temperatures without discomfort. It is recommended to use the inside of the wrist or a thermometer to ensure the water is warm but not hot, typically around 100°F (37.8°C), to prevent burns.
B. "Hold your baby under running water when washing his hair": Holding a newborn under running water is unsafe because it can cause sudden chilling, difficulty breathing, or even slipping. Instead, caregivers should use a damp, warm washcloth or gently pour water over the baby's head while securely supporting it.
C. "Cleanse the eyes from the inner canthus outward": Cleaning from the inner to the outer canthus is correct technique because it prevents introducing contaminants into the tear duct. This motion also minimizes the spread of bacteria, reducing the risk of eye infections in the delicate eyes of a newborn.
D. "Set the water heater to 125.6 degrees Fahrenheit": A water heater set to 125.6°F presents a high risk of scald burns in infants. Safety guidelines recommend setting the water heater to no higher than 120°F (48.9°C) to reduce the risk of accidental burns during bathing or household water use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "We will switch our baby's car seat to forward-facing when they turn one.": Current guidelines recommend keeping infants and toddlers in a rear-facing car seat until they reach the maximum height or weight limit of the seat, often well past one year, to provide optimal protection in a crash.
B. "We will check the temperature of the car seat surface before placing our baby in the seat when it is hot out.": This statement shows good understanding. Car seat surfaces can become dangerously hot and cause burns. Checking the seat temperature ensures the baby’s safety and comfort before securing them inside.
C. "We will make sure to activate the air bag when we place the car seat in the front passenger seat.": Airbags can cause serious injury or death to infants in rear-facing car seats. Car seats should always be placed in the back seat, and airbags should be deactivated if absolutely necessary to place a seat in the front, which is discouraged.
D. "We will wrap our baby in a blanket under the car seat straps when it is cold out.": Placing a blanket under the straps can prevent the harness from fitting snugly and securely. Instead, the harness should be fastened correctly first, and then a blanket can be placed over the baby for warmth.
Correct Answer is C
Explanation
A. Remind the client that they have been refusing the medication for 5 days: Pointing out the duration of refusal may come across as confrontational and does not respect the client's right to refuse treatment. It can also damage the therapeutic relationship without addressing the underlying concerns about the medication.
B. Inform the client that their provider will contact them to discuss their refusal of the medication: While involving the provider may eventually be necessary, the immediate nursing action should be to document the refusal accurately. The nurse can then inform the provider if needed based on facility policy.
C. Document the client's refusal in the medication administration record: Clients have the legal right to refuse medication, and it is the nurse’s responsibility to document the refusal clearly and objectively. Accurate documentation ensures legal protection for the client and the healthcare team and maintains the integrity of the medical record.
D. Notify the pharmacy about the client's refusal of the medication: Notifying the pharmacy about a single medication refusal is unnecessary unless there are repeated refusals requiring a change in the medication order. The pharmacy’s role is not to manage client compliance but to dispense prescribed medications.
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