Nokea
A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?
- A. A newborn who is 8 hr old and has acrocyanosis.
- B. A newborn who is 18 hr old and has not voided.
- C. A newborn who is 24 hr old and has not passed meconium.
- D. A newborn who is 12 hr old and has an axillary temperature of 37.8°C (100° F).
Correct Answer: D
Rationale: A temperature of 37.8°C may indicate infection, requiring immediate assessment, unlike the other less urgent findings.
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Which newborn is at the lowest risk for elevated unconjugated bilirubin levels?
- A. The newborn with significant bruising from a face presentation.
- B. The premature newborn.
- C. The baby born at 41 weeks' gestation.
- D. The newborn with O+ blood type, born to a mother with O- blood type.
Correct Answer: C
Rationale: A 41-week gestation newborn has a mature liver, minimizing bilirubin buildup compared to others with risk factors.
A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking?
- A. Moro.
- B. Rooting.
- C. Stepping.
- D. Babinski.
Correct Answer: B
Rationale: The rooting reflex triggers head-turning and mouth-opening when the cheek is stroked, facilitating breastfeeding.
In a newborn infant, which of the following is the liver's job related to bilirubin?
- A. Changing conjugated bilirubin to unconjugated.
- B. Synthesis of vitamin K.
- C. Changing unconjugated bilirubin to conjugated bilirubin.
- D. Removal of meconium.
Correct Answer: C
Rationale: The liver conjugates unconjugated bilirubin, making it water-soluble for excretion, preventing jaundice buildup.
A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching?
- A. I won't wear a bra during the daytime.
- B. I'll apply cold compresses 20 min before each feeding.
- C. I'll feed my baby every 2 hours.
- D. I will stop breastfeeding until I am done with the antibiotics.
Correct Answer: C
Rationale: Frequent feeding every 2 hours prevents and relieves engorgement by ensuring milk removal.
A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex?
- A. Perform a sharp hand clap near the infant.
- B. Turn the newborn's head quickly to one side.
- C. Place a finger at the base of the newborn's toes.
- D. Hold the newborn vertically, allowing one foot to touch the crib surface.
Correct Answer: A
Rationale: A sharp hand clap triggers the Moro reflex, causing arm extension and flexion, assessing neurological health.