A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well.
Which of the following statements should the nurse make?
"The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.”.
"Look at how she looks at you when you speak.
That's a good sign.”.
"We do routine hearing screenings on newborns.
You'll know before you leave the hospital if additional evaluation is recommended.”.
The Correct Answer is C
Choice A rationale
Clapping hands to assess hearing is not a reliable method and could startle the baby for reasons unrelated to hearing ability.
Choice B rationale
While a newborn might respond to visual stimuli, this is not a definitive method to assess hearing.
Choice C rationale
Routine hearing screenings using objective tests are the best way to determine a newborn's hearing ability, providing accurate and early detection of potential hearing issues.
Choice D rationale
This statement is misleading, as some forms of hearing loss can be inherited. It's important to use accurate methods to assess newborn hearing.
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Correct Answer is A
Explanation
Choice A rationale
A respiratory rate of 10/min is concerning as it indicates possible respiratory depression, which can be a side effect of spinal anesthesia. This requires immediate intervention to
prevent hypoxia and other complications.
Choice B rationale
Blood pressure of 100/70 mm Hg is within normal limits and does not require immediate intervention in this context.
Choice C rationale
Urinary output of 30 ml/hr is slightly low, but it is not immediately life-threatening. It may require monitoring and further assessment if it persists.
Choice D rationale
A headache pain rated a 6 on a scale of 0 to 10 could indicate a post-dural puncture headache, which is common after spinal anesthesia. It requires attention but is not an immediate
life-threatening condition. .
Correct Answer is B
Explanation
Choice A rationale
The fetal heartbeat cannot typically be heard via Doppler as early as 4 weeks of pregnancy. At this stage, the heart is still developing, and it is too soon for external detection with a Doppler device.
Choice B rationale
The fetal heartbeat is generally detectable by an external Doppler device around 10-12 weeks of pregnancy. This is the period when the heartbeat is strong enough to be picked up by the device.
Choice C rationale
Feeling the baby move, known as "quickening," typically occurs around 18-24 weeks of pregnancy, not 6 weeks. This sensation is different from hearing the heartbeat.
Choice D rationale
While the heart begins to form around week 5, it is not detectable by Doppler at 6 weeks. The technology does not have the sensitivity to detect such an early heartbeat externally.