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: Once healed, the area can be submerged in water during baths.
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The nurse is performing a gestational age assessment on a newborn. Which characteristic indicates the greatest gestational maturity?
- A. The infant's arms and legs are extended.
- B. There is some peeling and cracking of the skin.
- C. There are few rugae on the scrotum and the testes are high in the scrotum.
- D. The arm can be positioned with the elbow beyond the midline of the chest.
Correct Answer: B
Rationale: The correct answer is B because peeling and cracking of the skin, known as desquamation, is characteristic of a newborn born at term or post-term. This indicates the skin has been in contact with amniotic fluid for an extended period, typical of a more mature gestational age. Choices A, C, and D are incorrect as they do not specifically indicate gestational maturity. Arms and legs extended (A) can be seen in preterm infants. Few rugae on the scrotum and high testes (C) can be normal variations in newborns. The arm positioning (D) does not provide a direct indicator of gestational age.
Edward, a newborn delivered at 41 weeks' gestation, weighs 10 lb 4 oz. Vaginal delivery for this G1P1 mother was assisted with forceps. The nurse is completing her assessment and notes a sharply demarcated swelling over the parietal bones. The occipital and frontal skull bones are not affected. The neck does not appear edematous and is soft to the touch with full mobility. The infant is awake and active and has been breast-feeding well. What is the most probable cause of the swelling?
- A. cephalohematoma
- B. subgaleal hemorrhage
- C. caput succedaneum
- D. skull fracture
Correct Answer: A
Rationale: Cephalohematoma involves localized bleeding beneath the periosteum, typically over a single bone.
The family with a newborn diagnosed with cleft lip and palate is concerned about what will happen in the future. The birthing parent asks if they will be able to breast-feed the infant. What is the best response from the nurse?
- A. Newborns with cleft lip and palate require a special nipple and setup to receive full nutrition.
- B. Newborns with cleft lip and palate are unable to breast-feed but can have breast milk.
- C. Newborns with a cleft lip and palate may be able to breast-feed because latching may fill the gap.
- D. Newborns with cleft lip and palate are able to breast-feed only after surgical repair of their cleft.
Correct Answer: C
Rationale: Some infants with cleft lip and palate can breastfeed successfully depending on the severity and latching ability.
The nurse is preparing a new mother and newborn for discharge. Which statement indicates learning has occurred in the mother?
- A. I will feed my newborn every 3 hours while awake.'
- B. I will exclusively breastfeed my newborn every 2 to 3 hours.'
- C. I will supplement feedings with formula until my breast milk comes in.'
- D. Iron-fortified formula will be needed after my newborn is 6 months of age.'
Correct Answer: B
Rationale: The correct answer is B because it demonstrates understanding of the importance of exclusive breastfeeding every 2 to 3 hours. This statement shows the mother has learned about the recommended feeding schedule for newborns and the benefits of exclusive breastfeeding. Choice A is incorrect because feeding every 3 hours does not emphasize exclusive breastfeeding. Choice C is incorrect as supplementing with formula can interfere with establishing breastfeeding. Choice D is incorrect because iron-fortified formula is not typically needed if the baby is breastfed exclusively for the first 6 months.
A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the mother need to be taught to take care of the infant when she gets home.
- A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours
- B. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs
- C. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change
- D. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
Correct Answer: C
Rationale: Gentle cleansing with water and application of petroleum jelly protects the healing tissue and prevents irritation or sticking to the diaper.