Nokea
A home health nurse visits a 2-week-old infant and observes the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. Given these assessment findings, what instruction should the nurse give the parent?
- A. cover the umbilicus with a band-aid
- B. continue to clean the stump with alcohol for 1 week
- C. apply an antibiotic ointment to the stump
- D. give the baby a bath in an infant tub now
Correct Answer: D
Rationale: The correct answer is D: give the baby a bath in an infant tub now. This instruction is appropriate as the umbilical cord has dried and fallen off, indicating that the area is healed. Giving the baby a bath in an infant tub will help keep the area clean and promote healing.
A: Covering the umbilicus with a band-aid is unnecessary and may hinder air circulation, leading to potential infection.
B: Continuing to clean the stump with alcohol for 1 week is unnecessary as the cord has already fallen off and the area is healed.
C: Applying an antibiotic ointment to the stump is not recommended unless there are signs of infection, which are not present in this case.
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When the nurse determines they have a high-risk newborn and birthing person in their care, what can they do to mitigate the situation?
- A. Document in the chart.
- B. Reassure the parent that everything will be fine.
- C. Refer the couplet to social work for early intervention.
- D. Refer to a pediatric health-care provider for well-baby checkup.
Correct Answer: C
Rationale: The correct answer is C: Refer the couplet to social work for early intervention. This is the best course of action as social work can provide support and resources to address the high-risk situation. Documenting in the chart (A) is important but not sufficient for immediate intervention. Reassuring the parent (B) may be helpful, but it doesn't address the risk factor. Referring to a pediatric provider (D) is important but social work intervention can provide more comprehensive support in this specific situation.
A nurse is providing discharge teaching to parents of a newborn. The baby had no medical problems and is healthy other than having failed an automated auditory brainstem response (AABR) hearing test conducted in the nursery. What information does the nurse provide?
- A. AABR tests are conclusive and the baby is deaf.
- B. Background noise may have interfered with the test.
- C. The babys hearing should be retested within 1 month.
- D. The baby should have another hearing test next week.
Correct Answer: C
Rationale: Babies who fail a hearing screening test at birth should have a follow-up test within a month. The AARB test can be conducted in the presence of background noise. The results are not conclusive (it is a screening device)
The nurse notes swelling in the scrotum of a newborn infant. Transillumination reveals a reddish-yellow reflection. What action by the nurse is best?
- A. Document the findings and reassure the parents.
- B. Elevate the scrotum and apply ice for 20 minutes.
- C. Notify the health-care provider immediately.
- D. Obtain informed consent for emergent surgery.
Correct Answer: A
Rationale: When the nurse assesses a swollen scrotum, it is important to determine that the scrotal sac does not contain entrapped bowel or a mass. Transillumination can determine the presence of a mass when the light directed at the scrotum does not produce a reflection. A reddish-yellow reflection indicates fluid, which will be reabsorbed on its own. The nurse should document the findings and reassure the parents. No further action is needed.
The nurse is assessing a newborn girl born at 40 weeks of gestation based on the parent's LMP. What assessment finding of the genitalia confirms this gestational age?
- A. labia majora covering clitoris and labia minora
- B. clitoris prominent, labia minora enlarged
- C. small labia minora, clitoris enlarged
- D. labia majora enlarged, labia minora small
Correct Answer: A
Rationale: The correct answer is A because at 40 weeks of gestation, the labia majora should completely cover the clitoris and labia minora. This is known as the "laboratory majora sign" and is characteristic of full-term newborns.
Choice B is incorrect because a prominent clitoris and enlarged labia minora indicate a younger gestational age, typically around 36-38 weeks.
Choice C is incorrect as small labia minora and enlarged clitoris suggest a preterm newborn, around 32-34 weeks.
Choice D is incorrect as enlarged labia majora and small labia minora are more indicative of a post-term newborn, around 42 weeks or more.
Overall, the correct answer, choice A, aligns with the expected genitalia findings for a newborn born at 40 weeks of gestation based on the parent's LMP.
Which baby is at highest risk of skin infection upon discharge?
- A. Newborn with scabs forming over heels where blood has been drawn
- B. Newborn with a new circumcision
- C. Newborn with jaundice
- D. Newborn with milia
Correct Answer: B
Rationale: The correct answer is B, a newborn with a new circumcision, as this procedure involves an incision, making the baby more susceptible to skin infections. Circumcision wounds need proper care to prevent infection.
Choice A is incorrect because scabs forming over heels where blood has been drawn do not necessarily indicate a higher risk of skin infection. Choice C, a newborn with jaundice, is incorrect as jaundice affects the liver and does not directly increase the risk of skin infection. Choice D, a newborn with milia, is incorrect because milia are harmless and do not increase the risk of skin infection.