Nokea
A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take?
- A. Nothing because this is an acceptable weight loss.
- B. Advise the mother to supplement feedings with formula.
- C. Notify the neonatologist of the excessive weight loss.
- D. Give the baby dextrose water between breast feedings.
Correct Answer: A
Rationale: Weight loss within 5% is normal.
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A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?
- A. Place child in an isolette.
- B. Administer oxygen.
- C. Swaddle baby in a blanket.
- D. Apply pulse oximeter.
Correct Answer: C
Rationale: Cyanosis in extremities is normal in the first few hours due to peripheral vasoconstriction; swaddling provides warmth without unnecessary intervention.
It is time for a baby who is in the drowsy behavioral state to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select one that doesn't apply
- A. Swaddle or tightly bundle the baby.
- B. Hand express milk onto the baby's lips.
- C. Talk with the baby while making eye contact.
- D. Remove the baby's shirt and change the diaper.
Correct Answer: A
Rationale: Stimulating the baby with milk, voice, or tactile changes can encourage feeding.
A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make?
- A. Integrity of the baby's uvula.
- B. Presence of maternal nipple damage.
- C. Presence of neonatal tongue injury.
- D. The baby's breathing pattern.
Correct Answer: B
Rationale: Tongue-tie can lead to ineffective breastfeeding and nipple trauma.
A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose?
- A. Vitamin K.
- B. Protamine.
- C. Vitamin E.
- D. Mannitol.
Correct Answer: B
Rationale: Protamine reverses heparin effects.
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
- A. Remove wet blankets.
- B. Assess Apgar score.
- C. Insert eye prophylaxis.
- D. Elicit the Moro reflex.
Correct Answer: B
Rationale: Assessing the Apgar score is a priority immediately after birth to evaluate the newborn's overall condition.