Nokea
A faculty member explains to a nursing student that the best way to prevent hemorrhage from injuries in a neonate is which of the following?
- A. Administer vitamin K1 phytonadione (AquaMEPHYTON).
- B. Handle the infant carefully while wearing soft gloves.
- C. Keep the infant swaddled in several layers of blankets.
- D. Teach the parents how to trim the babys fingernails.
Correct Answer: A
Rationale: AquaMEPHYTON is given to newborns to promote normal blood clotting. The infants intestinal tract is sterile at birth and does not have the bacteria needed to create vitamin K
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A nurse is beginning a newborns physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best?
- A. Ask the mother to attempt to breastfeed the infant.
- B. Conduct the assessment quickly then swaddle the baby.
- C. Increase the heat in the room so the baby wont get chilled.
- D. Postpone the assessment until the infant has calmed.
Correct Answer: D
Rationale: An infant who seems irritable and overreacts to voices
A nurse is assessing an infant who has a large bruise around his neck and face from a nuchal cord. What other assessment finding correlates with this condition?
- A. Elevated serum bilirubin
- B. Irritability with gentle handing
- C. Large-for-gestational-age measurements
- D. Obvious vertebral defects
Correct Answer: A
Rationale: Infants born with a nuchal cord often demonstrate significant bruising to the face and neck. This may be upsetting to the parents. Irritability with handling might be related to damage from birth trauma. Large-for-gestational-age infants often have bruising related to extraction techniques during a difficult birth. Obvious vertebral defects are associated with neural tube anomalies and can be seen in children with hairy pigmented skin lesions and hairy nevi located in the posterior midline area near the spinal column.
The nurse knows that during the organizational process, the newborn won't be rated as exceptionally good if they do what?
- A. They will remain alert.
- B. They will be highly irritable and demonstrate mood swings.
- C. They will demonstrate self-soothing and quieting techniques.
- D. The newborn will shut down body responses to stimuli when drowsy.
Correct Answer: B
Rationale: The correct answer is B because a newborn being highly irritable and demonstrating mood swings is indicative of poor adaptability and self-regulation skills, which are factors considered in rating newborns. Being irritable and having mood swings can be signs of difficulty in self-soothing and adjusting to the environment, hence not meeting the criteria for being rated exceptionally good.
A: Remaining alert is generally a positive sign of responsiveness, so it wouldn't hinder the newborn from being rated as exceptionally good.
C: Demonstrating self-soothing and quieting techniques is a positive behavior that can contribute to a newborn being rated as exceptionally good.
D: Shutting down body responses to stimuli when drowsy is a normal physiological response and does not necessarily impact the newborn's rating as exceptionally good.
A postpartum nurse is giving guidance to a mother whose breast-fed newborn is experiencing hyperbilirubinemia. What are the best instructions for the nurse to give the mother in this case?
- A. It is best for the infant if she stops breast-feeding and switches to bottle-feeding permanently.
- B. The mother should switch to bottle-feeding until the baby’s bilirubin returns to normal range.
- C. The mother should alternate breast-feeding and bottle-feeding to ensure adequate fluid intake, until the baby’s bilirubin returns to normal range.
- D. The mother should continue to breast-feed the infant every 2 to 3 hours or more frequently as tolerated (every 2 hours if under phototherapy).
Correct Answer: D
Rationale: Continued frequent breastfeeding helps reduce bilirubin levels effectively.
An infant who was stable for a day after birth now demonstrates pallor tachycardia tachypnea and circumoral cyanosis. The parent asks how the child might have a heart problem when he was stable yesterday. What information by the nurse is most accurate?
- A. Blood incompatibilities can cause this problem so we will test the mothers blood.
- B. Symptoms may not appear until fetal circulation routes begin to close after birth.
- C. The extra blood from the umbilical cord may have kept the baby stable for a while.
- D. Your baby may have gotten an infection during birth that now is causing problems.
Correct Answer: B
Rationale: This baby has clinical manifestations of tetralogy of Fallot. While the ductus arteriosus remains patent the infant remains stable. However when the ductus begins closing after the first 24 hours of life the infants cardiovascular system becomes unstable and manifestations appear. The other statements are inaccurate.