Level: Advanced
Difficulty: Hard
Subtopic: Newborn safety
NCLEX: A 38-week newborn on the mother-baby unit is being evaluated for newborn care on the postpartum unit. Assessment…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 38-week newborn on the mother-baby unit is being evaluated for newborn care on the postpartum unit. Assessment data include temperature 36.1°C (97°F) after the first bath. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.