Nokea
A mother delivered her baby at midnight and it is now 9 a.m. She wants to sleep and asks the nurse to take care of the baby. What is this considered?
- A. Fatigue from labor
- B. Normal "taking in" response
- C. Abnormal "taking in" response
- D. Risk for altered maternal-infant bonding
Correct Answer: B
Rationale: Her primary focus will be on her own needs such as sleep ("taking in" stage).
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Which finding should the nurse suspect as abnormal in the newborn during the initial assessment?
- A. Eyes crossed at times
- B. Persistent high-pitched cry
- C. Arms and legs flexed
- D. Slight bluish tinge of the extremities
Correct Answer: B
Rationale: A high-pitched cry may indicate neurologic problems. Occasional crossing of the eyes, flexing of the arms and legs, and a bluish tinge of the extremities are all considered normal assessment findings in the newborn.
Before initially feeding an infant what reflex should the nurse assess?
- A. Moro reflex
- B. Rooting reflex
- C. Babinski reflex
- D. Swallow reflex
Correct Answer: D
Rationale: The nurse should verify that the infant is able to swallow normally before feeding.
After delivery of a 9-lb baby the nurse assesses a perineal laceration extending through the muscles of the perineum. The nurse records this as a ___-degree laceration.
Correct Answer: second
Rationale: A second-degree laceration extends through the superficial tissues into the muscles of the perineum.
What is a characteristic of a normal breast-fed infant's stool?
- A. Green and loose
- B. Dark green and sticky
- C. Pale yellow and frequent
- D. Light brown and pasty
Correct Answer: C
Rationale: Breast-fed infants tend to pass stools frequently and they are pale yellow to golden in color and pasty in consistency.
Where would acrocyanosis be assessed on a newborn?
- A. Circumoral area
- B. Brow
- C. Feet
- D. Mucous membrane
Correct Answer: C
Rationale: Acrocyanosis is the slightly blue appearance of the hands and feet that is caused by poor circulation. It can last for 7 to 10 days in the newborn.