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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. "If I have a health care proxy, then I do not need to have a living will.": A health care proxy and a living will serve different purposes. A living will outlines specific treatment preferences, while a health care proxy designates someone to make decisions. Having one does not eliminate the benefit or need for the other.

B. "My health care proxy designee is not able to sign a consent form on my behalf.": The designee named in a health care proxy is specifically authorized to make healthcare decisions, including signing consent forms, if the client becomes unable to do so themselves.

C. "I do not need to name a relative as my designee in my health care proxy.": A client can choose any competent adult they trust to act as their healthcare proxy; it does not have to be a relative. This flexibility allows clients to select someone they believe will best honor their wishes.

D. "Once my health care proxy is in place, I relinquish my right to make my own decisions.": Having a health care proxy does not remove the client's decision-making rights. The proxy only takes effect if the client becomes unable to make or communicate their own healthcare decisions.

A. Difficulty swallowing B. Constipation C. Urinary retention D. Restlessness

Correct Answer is D

Explanation

A. Difficulty swallowing: Difficulty swallowing, or dysphagia, is not typically a direct indicator of unrelieved pain. It could suggest neurological or throat-related issues rather than being a primary symptom associated with inadequate pain control.

B. Constipation: Constipation is a common postoperative complication, often related to anesthesia, immobility, or opioid use. While it is important to address, it does not directly reflect the client's current pain level or effectiveness of pain management.

C. Urinary retention: Urinary retention can occur due to anesthesia effects, pelvic surgery, or opioid administration. Although it is a significant postoperative concern, it is not a reliable or direct indicator of unrelieved pain.

D. Restlessness: Restlessness is a common sign of unrelieved pain, particularly in postoperative clients. When clients are uncomfortable or in significant pain, they may appear restless, anxious, or unable to remain still, signaling the need for further pain assessment and intervention.

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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?

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Naxlex Comprehensive Predictor Exams

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