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A nurse is assisting with the care of a client who is in the third trimester of gestation.Which of the following statements by the client’s partner indicates effective adaptation to their new role?

A.

“I don’t want to call the baby by name until the baby is born.”.

B.

“I need to start painting the baby’s room.”.

C.

“I can’t wait until my child is old enough to enjoy my hobbies with me.”.

D.

“I am waiting until the baby is born to share the news with coworkers.”

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Not wanting to call the baby by name until the baby is born can be a cultural or personal preference and does not necessarily indicate effective adaptation to the new role. It may reflect a cautious approach to the pregnancy but does not provide evidence of active preparation or involvement.

 

Choice B rationale

 

Starting to paint the baby’s room is a proactive behavior that indicates the partner is preparing for the baby’s arrival. It shows that the partner is taking steps to create a welcoming environment for the baby, which is a positive sign of adaptation to the new role.

 

Choice C rationale

 

Looking forward to sharing hobbies with the child in the future is a positive indication of the partner’s excitement and anticipation for the baby’s growth and development. However, it does not directly reflect immediate preparation or involvement in the pregnancy.

 

Choice D rationale

 

Waiting until the baby is born to share the news with coworkers may reflect a cautious approach to the pregnancy but does not indicate active involvement or preparation for the baby’s arrival. It may be a personal preference but does not demonstrate effective adaptation to the new role.


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Correct Answer is C

Explanation

Choice A rationale

Applying lotion to the newborn’s extremities every 8 hours is not recommended during phototherapy. Lotions and ointments can cause burns when exposed to phototherapy lights and may interfere with the treatment’s effectiveness.

Choice B rationale

Repositioning the newborn every 4 hours is not frequent enough. The newborn should be repositioned every 2 hours to ensure even exposure to the phototherapy light and to prevent pressure sores.

Choice C rationale

Removing the eye mask during feedings is correct. The eye mask should be removed during feedings to allow for bonding and to check for any signs of irritation or infection. This also ensures that the newborn’s eyes are protected from the phototherapy light when not under the lamp.

Choice D rationale

Supplementing feedings with glucose water is not recommended. Breast milk or formula should be used to ensure the newborn receives adequate nutrition and hydration. Glucose water does not provide the necessary nutrients and can interfere with breastfeeding.

Correct Answer is ["E","F"]

Explanation

Choice A rationale:

The head assessment finding is not mentioned as abnormal in the exhibits. The anterior fontanelle is soft and flat, which is a normal finding in newborns. This indicates that there is no increased intracranial pressure or dehydration. The head circumference and shape are also not noted to have any abnormalities, which suggests that the newborn’s head development is within normal limits.

Choice B rationale:

The glucose level is not provided in the exhibits. However, routine glucose monitoring is not typically required for healthy, term newborns unless they exhibit symptoms of hypoglycemia or have risk factors such as being large for gestational age, small for gestational age, or born to mothers with diabetes. Since the newborn is feeding well and has no signs of hypoglycemia, there is no immediate concern regarding glucose levels.

Choice C rationale:

The mucous membrane assessment shows that the mucous membranes are moist and pink, which is a normal finding. This indicates that the newborn is well-hydrated and has good perfusion. There are no signs of dehydration, pallor, or lesions in the oral cavity, which suggests that the newborn’s mucous membranes are healthy.

Choice D rationale:

The intake and output are adequate, as evidenced by the number of wet diapers and stools. The newborn has had six wet diapers and three stools in the past 24 hours, which is within the normal range for a healthy, breastfed newborn. This indicates that the newborn is receiving sufficient nutrition and is well-hydrated.

Choice E rationale:

The respiratory rate of 44/min is on the higher end of the normal range for newborns, which is typically 30-60 breaths per minute. However, it is important to monitor for any signs of respiratory distress or abnormalities, such as grunting, flaring, or retractions. Reporting this finding ensures that any potential issues are addressed promptly.

Choice F rationale:

The heart rate of 154/min is within the normal range for newborns, which is typically 120-160 beats per minute. However, it is on the higher end of the spectrum. Monitoring and reporting this finding is crucial to ensure that the newborn’s cardiovascular status remains stable and to rule out any underlying conditions that may require intervention.

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