What two steps of the CJMM are included in the assessment step of the nursing process?

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PN Maternal Newborn Online Practice 2023 A Questions

Question 1 of 5

What two steps of the CJMM are included in the assessment step of the nursing process?

Correct Answer: A

Rationale: In the assessment step of the nursing process, two steps of the CJMM (Clinical Judgment Model) that are included are noticing cues and evaluating outcomes. Noticing cues involves observing and recognizing relevant information or data related to the patient's health status, while evaluating outcomes involves assessing the effectiveness of the nursing interventions and patient responses to the care provided. By noticing cues, nurses gather information that guides their decision-making process, and by evaluating outcomes, they determine the impact of their actions on the patient's health and adjust the plan of care as needed. These two steps are essential in the assessment phase as they contribute to developing a comprehensive understanding of the patient's needs and progress towards achieving desired health outcomes.

Question 2 of 5

The nurse is caring for a postpartum client who is

Correct Answer: A

Rationale: Maternal hyperglycemia 1 day post-cesarean birth can indicate infection. Hyperglycemia can impair immune function and make the body more susceptible to infections.

Question 3 of 5

A newborn is delivered vaginally in the breech presentation. When examining her baby, the mother asks if the baby has been injured during birth because of the large black and blue areas on the buttocks and legs, The nurse should respond that:

Correct Answer: A

Rationale: The large black and blue areas on the buttocks and legs of the newborn are likely Mongolian spots. Mongolian spots are common in infants with dark skin and are not a result of birth trauma. They are benign birthmarks caused by pigment that did not make it to the top layer of the skin before birth. These spots typically fade over time and may disappear completely within a few years. It is important to educate parents about Mongolian spots to alleviate any concerns they may have about their baby's skin markings.

Question 4 of 5

A nurse is caring for a newborn who is 6 hr. old and has a bedside glucometer reading of 65 mg/ dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: The correct action for the nurse to take in this situation is to reassess the blood glucose level prior to the next feeding. A single low bedside glucometer reading is not sufficient to make treatment decisions, especially in a newborn who is only 6 hours old and with a mother having type 2 diabetes mellitus. It is important to follow up with another blood glucose measurement before taking further action. This will help ensure that appropriate interventions are taken based on accurate and reliable information.

Question 5 of 5

What is the most important teaching for a mother of a preterm infant in an incubator?

Correct Answer: C

Rationale: Educating about kangaroo care promotes bonding and stabilizes the infant's vital signs.

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