Nokea
A neonates 5-minute Apgar assessment reveals the following: active motion; pulse
- A. 126 beats/minute; grimace and coughing during suctioning; appearance
- B. good color all over; and respirations slightly irregular with weak cry. What action by the nurse is most appropriate?
- C. Assess oxygen saturation and administer oxygen if needed.
- D. Document the findings in the chart and begin the identification process.
Correct Answer: A
Rationale: The babys 5-minute Apgar score is 8 (motion 2; pulse 2; grimace 2; appearance 1; respirations 1). If a 5-minute Apgar score is less than 9 the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this babys problems are related to either oxygenation or perfusion the nurse should assess the oximetry reading and administer oxygen if needed.
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To prevent breast engorgement, what should the new breastfeeding mother be instructed to do?
- A. Feed her infant no more than every 4 hours.
- B. Limit her intake of fluids for the first few days.
- C. Apply cold packs to the breast prior to feeding.
- D. Breast-feed frequently and for adequate lengths of time.
Correct Answer: D
Rationale: The correct answer is D because frequent and adequate breastfeeding helps prevent breast engorgement by ensuring proper milk flow and emptying of the breasts. This stimulates milk production and prevents blockages. Choice A is incorrect as spacing out feedings can lead to engorgement. Choice B is incorrect as hydration is important for milk production. Choice C is incorrect as cold packs can reduce milk flow and hinder breastfeeding. In summary, frequent and effective breastfeeding is crucial in preventing breast engorgement.
The nurse is assigned to the postpartum room of a 12-hour-old neonate, and the EHR has a task reminder prompting the nurse to complete a Brazelton assessment on the newborn. Why is this not appropriate?
- A. This newborn has been born to a person who is placing the infant up for adoption.
- B. This newborn has been born to a person who birthed by cesarean section.
- C. This newborn is only 12 hours old.
- D. This newborn is experiencing pathologic jaundice.
Correct Answer: C
Rationale: The correct answer is C because performing a Brazelton assessment on a newborn who is only 12 hours old is not appropriate. The Brazelton assessment is typically done within the first 24-36 hours of life. Performing it too early may yield inaccurate results as the newborn is still transitioning and adapting to life outside the womb.
Choice A is not relevant to the appropriateness of the assessment timing. Choice B also does not impact the timing of the assessment. Choice D is also irrelevant to the timing of the assessment and would not affect the decision to delay performing the Brazelton assessment.
Which statement is the most accurate regarding suctioning of the oral and nasal passages of a newborn?
- A. The bulb syringe should be compressed after it is inserted into the baby's nose to suction.
- B. Suction the nose and then the mouth of the newborn to prevent aspiration.
- C. Saline should be placed in the baby's nose and mouth prior to suctioning.
- D. Place the bulb syringe on the side of the infant's cheek while suctioning the mouth.
Correct Answer: B
Rationale: The correct answer is B: Suction the nose and then the mouth of the newborn to prevent aspiration. This is the most accurate statement because suctioning the nose first prevents any mucus or secretions from being pushed into the mouth during suctioning. Aspiration can occur if the baby inhales any secretions. Suctioning the mouth after the nose ensures that any remaining secretions are cleared.
Choice A is incorrect because compressing the bulb syringe after insertion can cause trauma to the delicate nasal passages. Choice C is incorrect as using saline before suctioning is not necessary and may increase the risk of aspiration. Choice D is incorrect as placing the bulb syringe on the side of the infant's cheek is not an effective method for suctioning the mouth or nose.
The nurse is evaluating the involution of a woman who is 3 days post partum. Which of the following finding would the nurse evaluate as normal?
- A. Fundus 1 cm above the umbilicus, lochia rosa.
- B. Fundus 2 cm above the umbilicus, lochia alba.
- C. Fundus 2 cm below the umbilicus, lochia rubra.
- D. Fundus 3 cm below the umbilicus, lochia serosa.
Correct Answer: D
Rationale: By day 3, the fundus should descend to 3 cm below the umbilicus, and lochia should transition to serosa.
When assessing a newborn baby
- A. which action should the nurse perform first?
- B. Auscultate the babys heart and lungs.
- C. Don clean gloves before taking the baby.
- D. Record the parents choice of name.
Correct Answer: B
Rationale: The nurse should observe standard precautions when handling a neonate until all blood and amniotic fluid has been removed to avoid possible infection. Then the nurse can take the baby and suction the babys mouth and then the nares if needed. Auscultating the babys heart and lungs will occur later. The parents may not name the baby immediately but even if they have recording the name would not take priority over using standard precautions to prevent the spread of disease.