Nokea
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.
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Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level?
- A. Distended bladder
- B. Normal involution
- C. Been lying on her right side too long
- D. Stretched ligaments that are unable to support the uterus
Correct Answer: A
Rationale: The correct answer is A, a distended bladder. When the fundus is palpated on the right side above the expected level, it indicates that the bladder is full and pushing the uterus upward and to the right. This can interfere with the normal descent of the uterus during involution, leading to the fundus being higher than expected.
Choice B, normal involution, is incorrect as it does not explain the fundus being palpated above the expected level.
Choice C, lying on her right side too long, is incorrect as body position does not typically result in the fundus being displaced.
Choice D, stretched ligaments that are unable to support the uterus, is incorrect as stretched ligaments would not cause the fundus to be palpated above the expected level; rather, it would lead to a lower position of the uterus.
A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal?Select one that doesn't apply
- A. Purple-colored patches on the buttocks and torso.
- B. Bilateral whitish discharge from the breasts.
- C. Bloody discharge from the vagina.
- D. Sharply demarcated dark red area on the face.
Correct Answer: D
Rationale: Transient phenomena such as mongolian spots, witch's milk, and pseudo-menstruation are normal in newborns.
The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see?
- A. When the cheek of the baby is touched
- B. the newborn turns toward the side that is touched.
- C. When the lateral aspect of the sole of the baby's foot is stroked
- D. the toes extend and fan outward.
Correct Answer: C
Rationale: Moro reflex involves extension of arms and flexion of knees in response to a sudden stimulus.
A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit?
- A. Hallucinations.
- B. Polyphagia.
- C. Induced vomiting.
- D. Weepy sadness.
Correct Answer: A
Rationale: Hallucinations are characteristic of psychosis.
The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select one that doesn't apply
- A. Hypothyroidism.
- B. Sickle cell disease.
- C. Galactosemia.
- D. Cerebral palsy.
Correct Answer: D
Rationale: These are common conditions screened for in neonatal blood tests; cerebral palsy is not typically screened through blood tests.