a 6 month old child who had a cleft lip repair has elbow restraints in place what nursing intervention should the nurse plan to implement
Logo

Nursing Elites

HESI RN

Maternity HESI 2023 Quizlet

1. A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?

Correct answer: B

Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.

2. The client delivered hours ago and has a boggy uterus displaced above and to the right of the umbilicus. What action should the nurse take?

Correct answer: B

Rationale: A boggy uterus that is displaced above and to the right of the umbilicus may indicate a full bladder, which can impede uterine contraction and lead to hemorrhage. Encouraging the client to void helps relieve pressure on the uterus, promoting better contraction and preventing postpartum hemorrhage.

3. After breastfeeding for 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?

Correct answer: B

Rationale: After a newborn spits up breast milk following feeding, the priority action for the nurse is to sit the newborn upright and burp by rubbing or patting the upper back. This position helps release trapped air and reduces the likelihood of further spit-up or aspiration. It is essential to address this first to prevent potential complications and ensure the newborn's comfort and safety.

4. A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?

Correct answer: C

Rationale: Assessing bilateral lung sounds is crucial in this scenario as it can provide essential information about potential fluid accumulation in the lungs, indicating worsening heart failure. This assessment can guide immediate interventions to prevent further deterioration in the patient's condition.

5. A newborn's parents tell the nurse that their baby is already trying to walk. How should the nurse respond?

Correct answer: D

Rationale: When parents report that their newborn is trying to walk, the nurse should understand that newborns exhibit a stepping reflex, which is a normal developmental response. Explaining this reflex to the parents helps them understand that it is a typical behavior seen in newborns rather than true attempts to walk. Encouraging the parents to report this to the healthcare provider (Choice A) may cause unnecessary concern since the stepping reflex is a normal part of newborn development. Acknowledging the parents' observation (Choice B) is a good communication strategy but providing education on the normal reflex is essential. Scheduling the newborn for further neurological testing (Choice C) is not indicated in this scenario as the stepping reflex is a typical finding in newborns.

Similar Questions

A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?
When preparing a class on newborn care for expectant parents, what content should be taught concerning the newborn infant born at term gestation?
A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?
A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses