Nokea
The nurse has just assisted with the birth of a full-term infant. The nurse should take which measures immediately to promote parent-infant attachment? Select all that apply.
- A. Have the mother nap before interacting with her newborn.
- B. Dim the lights in the birthing room.
- C. Place the newly delivered infant on the mother’s abdomen.
- D. Delay instilling the ophthalmic antibiotic for an hour.
- E. Play loud music to keep the infant stimulated.
- F. Ask the parents to delay phone calls for an hour after birth.
Correct Answer: B,C,D,F
Rationale: Dimming lights encourages eye contact skin-to-skin contact improves interaction delaying antibiotic ointment prevents blurred vision and delaying phone calls maximizes bonding time. Napping misses the alert period and loud music is overstimulating.
You may also like to solve these questions
While supervising the LPN,the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse’s conclusion?
- A. Assessed the newborn’s heart rate apically
- B. Covered the newborn’s head with a stocking cap
- C. Checked the newborn’s temperature rectally
- D. Positioned the newborn supine while sleeping
Correct Answer: C
Rationale: Rectal temperature checks risk mucosal irritation or perforation. Apical HR assessment stocking caps and supine positioning (to reduce SIDS risk) are correct practices.
If the nurse collects the following data, which assessment finding best indicates the presence of increased intracranial pressure?
- A. Rapid bilateral pupillary response to light
- B. Tympanic temperature of 97.9°F (36.6°C)
- C. Blood pressure of 150/90 mm Hg
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: Elevated blood pressure (e.g., 150/90 mm Hg) is a sign of increased intracranial pressure, often part of Cushing's triad (hypertension, bradycardia, irregular respirations), indicating brain compression.
Which statement by the nurse is most therapeutic in addressing the teen's behavior?
- A. There's nothing to be scared of. This won't hurt.
- B. The stitches are strong. They won't come out.
- C. I know you're scared, but you must be brave.
- D. Let's do this later, when you're better prepared.
Correct Answer: C
Rationale: Acknowledging the teen's fear and encouraging bravery validates their emotions while gently motivating them to proceed with ambulation, fostering trust and cooperation.
Which assessment finding is most indicative of a child with a protein deficiency?
- A. Brittle hair and dry skin
- B. Frequent nosebleeds
- C. High fever and chills
- D. Rapid weight gain
Correct Answer: A
Rationale: Protein deficiency can lead to brittle hair and dry skin due to inadequate protein for tissue repair and maintenance, a hallmark of conditions like kwashiorkor.
During preoperative preparation, which nursing action is most appropriate?
- A. Give analgesics.
- B. Give nothing by mouth (NPO).
- C. Give an enema.
- D. Apply heat to the abdomen.
Correct Answer: B
Rationale: Keeping the patient NPO prevents aspiration during surgery and reduces complications, as food in the stomach could interfere with anesthesia.