The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

The baby sleeps with the mother in bed.

The windows are covered with screens.

The kitchen has a refrigerator.

The baby has a changing area.

Answer and Explanation

The Correct Answer is A

The baby sleeps with the mother in bed. This is because sleeping with the baby in the same bed increases the risk of sudden infant death syndrome (SIDS), suffocation, strangulation, and entrapment. The nurse should have assessed the mother’s sleeping arrangements for the baby and provided education on safe sleep practices before discharge. The nurse should advise the mother to place the baby on a firm surface, such as a crib or bassinet, in the same room but not in the same bed as the mother.

Choice B is wrong because having windows covered with screens is not a sign of inadequate home assessment. Screens can help prevent insects and other animals from entering the home and posing a health hazard.

Choice C is wrong because having a refrigerator in the kitchen is not a sign of inadequate home assessment. A refrigerator can help store food and breast milk safely and prevent spoilage and contamination.

Choice D is wrong because having a changing area for the baby is not a sign of inadequate home assessment. A changing area can help keep the baby clean and comfortable and prevent diaper rash and infection.

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Correct Answer is C

Explanation

Administer low concentrations of oxygen. Retinopathy of prematurity (ROP) is a disease of retinal vascular and capillary proliferation affecting premature infants undergoing oxygen therapy. Oxygen treatment results in pathologic growth of vessels in the developing retina that may lead to permanent damage to the retina as well as retinal detachment and macular folds. Administering low concentrations of oxygen can help prevent ROP by reducing the oxygen-induced vasoconstriction and vascular endothelial growth factor (VEGF) expression.

Choice A is not correct because keeping the infant's eyes covered at all times does not prevent ROP. In fact, it may increase the risk of infection or injury to the eyes.

Choice B is not correct because positioning with the head slightly lower than the body does not prevent ROP. It may increase the intracranial pressure and affect the cerebral blood flow.

Choice D is not correct because monitoring arterial oxygen levels with a pulse oximeter does not prevent ROP. It is a useful tool to guide oxygen therapy, but it does not directly affect retinal vascular development.

A. Blood pressure B. Amount of lochia C. Fulness of the bladder D. Level of pain

Correct Answer is C

Explanation

Fullness of the bladder. A boggy uterus with the fundus above the umbilicus and deviated to the side indicates that the uterus is not contracting properly and may be displaced by a full bladder. A full bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The nurse should assess the bladder and assist the patient to empty it if needed.

Choice A. Blood pressure is not the next assessment because it is not related to the position and tone of the uterus. Blood pressure may be affected by blood loss, but it is not a priority in this situation.

Choice B. Amount of lochia is not the next assessment because it is not related to the position and tone of the uterus. Lochia may be increased or decreased depending on the uterine contraction, but it is not a priority in this situation.

Choice D. Level of pain is not the next assessment because it is not related to the position and tone of the uterus. Pain may be present due to uterine cramping or other factors, but it is not a priority in this situation.

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The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

Correct Answer is C

Explanation

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

Correct Answer is C

Explanation

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

To protect newborns from infection while in the nursery, the nurse plans to:

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is:

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?