Nokea
A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby's face is"purple." Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following?
- A. Petechiae are indicative of severe bacterial infections.
- B. Rapid deliveries can injure the neonatal presenting part.
- C. Petechiae are characteristic of the normal newborn rash.
- D. The injuries are a sign that the child has been abused.
Correct Answer: B
Rationale: Petechiae can result from pressure changes during rapid delivery, particularly affecting the presenting part.
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A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform?
- A. Cover the wound with sterile wet dressings.
- B. Notify the surgeon.
- C. Elevate the head of the client's bed slightly.
- D. Flex the client's knees.
Correct Answer: B
Rationale: Immediate surgical intervention is required for wound separation.
A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician?
- A. If the baby feeds 8 to 12 times each day.
- B. If the baby urinates 6 to 10 times each day.
- C. If the baby has stools that are watery and bright yellow.
- D. If the baby has eyes and skin that are tinged yellow.
Correct Answer: D
Rationale: Jaundice may indicate hyperbilirubinemia.
A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate?
- A. That is correct. The rice cereal takes longer for them to digest so they sleep better and longer.
- B. It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives.
- C. It is too early for rice cereal
- D. but I would recommend giving apple sauce at 3 months of age and apple juice 1 month later.
Correct Answer: B
Rationale: Exclusive breastfeeding is recommended for the first 6 months.
The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included?
- A. Clean the eyes from outer canthus to inner canthus.
- B. Cleanse the ear canals with a cotton swab.
- C. Assemble all supplies before beginning the bath.
- D. Check the temperature of the bath water with the fingertips.
Correct Answer: C
Rationale: Preparing supplies ensures efficiency and safety during bathing.
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, he preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse’s priority action with this finding?
- A. Weigh the peripad.
- B. Replace the peripad.
- C. Contact the health care provider.
- D. Document the finding in the patient’s chart.
Correct Answer: C
Rationale: The correct answer is C: Contact the health care provider. This is the priority action because the sudden increase in lochia flow after breastfeeding could indicate postpartum hemorrhage, which is a serious complication that requires immediate medical attention. Contacting the healthcare provider will allow for prompt assessment and intervention.
A: Weigh the peripad - This is not the priority action as assessing the amount of blood loss is important, but contacting the healthcare provider for further assessment and intervention takes precedence.
B: Replace the peripad - While maintaining cleanliness and hygiene is important, addressing the potential postpartum hemorrhage is the priority.
D: Document the finding in the patient’s chart - Documentation is necessary but should come after the immediate concern of postpartum hemorrhage is addressed.