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A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select one that doesn't apply
- A. Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs.
- B. Gently adduct and abduct the baby's thighs.
- C. Palpate the trochanter during hip rotation.
- D. Place the baby in a fetal position.
Correct Answer: D
Rationale: These maneuvers help detect instability or asymmetry in the hips indicative of DDH.
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The nurse is caring for a client, G3 P2002, whose infant has been diagnosed with a treatable birth defect. Which of the following is an appropriate statement for the nurse to make?
- A. Thank goodness. It could have been untreatable.
- B. I'm so happy that you have other children who are healthy.
- C. These things happen. They are the will of God.
- D. It is appropriate for you to cry at a time like this.
Correct Answer: D
Rationale: Validation of emotions is supportive.
The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby who exhibited visible birth defects. Which of the following actions by the nurse is appropriate?
- A. Discourage the parents from naming the baby.
- B. Advise the parents that the baby's defects would be too upsetting for them to see.
- C. Transport the baby to the morgue as soon as possible.
- D. Give the parents a lock of the baby's hair and a copy of the footprint sheet.
Correct Answer: D
Rationale: Providing keepsakes helps with grieving.
A postpartum patient asks, “Will these stretch marks ever go away?” Which is the nurse’s best response?
- A. “No, never.”
- B. “Yes, eventually.”
- C. “They will fade to silvery lines but won’t disappear completely.”
- D. “They will continue to fade and should be gone by your 6-week checkup.”
Correct Answer: C
Rationale: The correct answer is C: “They will fade to silvery lines but won’t disappear completely.” This response is the best because it provides a realistic expectation to the patient. Stretch marks may lighten over time but typically do not completely disappear. Choice A is incorrect as it provides a definitive and discouraging answer. Choice B is vague and does not offer a clear timeframe. Choice D is incorrect as it gives an overly optimistic timeline that may not be realistic for most individuals. Overall, choice C is the most accurate and supportive response for the patient's query.
The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching by the nurse in the hospital was successful?
- A. The client is breastfeeding her baby every two hours.
- B. The client is using a diaphragm for family planning.
- C. The client is taking her temperature every morning.
- D. The client is seeking care for a recent weight loss.
Correct Answer: D
Rationale: Weight loss may indicate opportunistic infection.
Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma?
- A. Pain.
- B. Bleeding.
- C. Warmth.
- D. Redness.
Correct Answer: A
Rationale: Pain is a common symptom of a vaginal hematoma.