Nokea
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.
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A breastfeeding woman calls the pediatric nurse with the following complaint:"I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?" Which of the following replies by the nurse is appropriate at this time?
- A. Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes.
- B. Don't forget to pump your breasts every 3 hours while the baby is being fed the prescribed formula.
- C. The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula.
- D. In addition to giving the baby formula, you should wear a surgical face mask when you are around him.
Correct Answer: C
Rationale: Breastfeeding provides antibodies to protect the baby.
A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select one that doesn't apply.
- A. Babies have a poorly developed sense of smell until they are 2 months old.
- B. Babies respond to all forms of taste well
- C. but they prefer to eat sweet things like breast milk.
- D. Babies are especially sensitive to being touched and cuddled.
Correct Answer: A
Rationale: Newborns have limited senses initially but can distinguish tastes, enjoy touch, and have limited vision until around 3 months.
The nurse educates the non–breast-feeding person on breast discomfort caused by engorgement. What instructions would they give?
- A. Massage breasts to release milk.
- B. Apply cold packs and cabbage leaves.
- C. Stand in the warm shower to stimulate letdown.
- D. Do not wear a bra.
Correct Answer: B
Rationale: The correct answer is B: Apply cold packs and cabbage leaves. Engorgement causes breast swelling and discomfort due to increased blood and milk supply. Applying cold packs reduces inflammation and pain. Cabbage leaves have a cooling effect and can help reduce swelling. Massaging breasts can worsen engorgement by stimulating more milk production. Standing in a warm shower may provide temporary relief but does not address the root cause. Not wearing a bra may lead to discomfort and does not alleviate engorgement.
What is the term for the separation found in the midline of the abdomen after birth?
- A. uterine subinvolution
- B. umbilical hernia
- C. striae
- D. diastasis recti abdominus
Correct Answer: D
Rationale: The correct answer is D: diastasis recti abdominus. This term refers to the separation of the rectus abdominis muscles along the midline of the abdomen. This condition commonly occurs after pregnancy due to the stretching of the abdominal muscles. It is important to differentiate diastasis recti from other conditions such as uterine subinvolution, which is the delayed return of the uterus to its normal size postpartum; umbilical hernia, which is a protrusion of abdominal contents through the umbilical ring; and striae, which are stretch marks caused by rapid stretching of the skin. Diastasis recti is characterized by a visible gap between the muscles, often causing a bulge in the midline of the abdomen. Treatment usually involves specific exercises to strengthen the abdominal muscles and improve the condition.
The person with a cesarean birth has additional nursing concerns beyond those of a person with a vaginal birth. What concern should the nurse anticipate for the cesarean birth?
- A. increased risk for DVT
- B. faster recovery
- C. less use of pain medication
- D. less risk for infection
Correct Answer: A
Rationale: The correct answer is A: increased risk for DVT. Cesarean birth increases the risk of Deep Vein Thrombosis (DVT) due to reduced mobility and potential blood clot formation. This is a critical concern as DVT can lead to serious complications like pulmonary embolism. Choices B and C are incorrect as cesarean birth typically results in longer recovery time and increased need for pain medication compared to vaginal birth. Choice D is incorrect as cesarean birth poses a higher risk of infection due to the surgical incision.