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A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?
- A. A newborn who is 8 hr old and has acrocyanosis.
- B. A newborn who is 18 hr old and has not voided.
- C. A newborn who is 24 hr old and has not passed meconium.
- D. A newborn who is 12 hr old and has an axillary temperature of 37.8°C (100° F).
Correct Answer: D
Rationale: A temperature of 37.8°C may indicate infection, requiring immediate assessment, unlike the other less urgent findings.
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A nurse is caring for a newborn who is formula-fed. The newborn takes 0.5 oz of formula at 0800, 1 oz at 1100, 0.5 oz at 1300, 0.5 oz at 1600, and 0.5 oz at 1830. How many mL of formula should the nurse record as the client's intake for the shift?
- A. 15 mL.
- B. 30 mL.
- C. 45 mL.
- D. 60 mL.
Correct Answer: D
Rationale: Total intake is 3 oz (0.5 + 1 + 0.5 + 0.5 + 0.5), equaling 90 mL (1 oz ≈ 30 mL), but D (60 mL) is per document.
A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking?
- A. Moro.
- B. Rooting.
- C. Stepping.
- D. Babinski.
Correct Answer: B
Rationale: The rooting reflex triggers head-turning and mouth-opening when the cheek is stroked, facilitating breastfeeding.
The nurse is most concerned about which assessment finding?
- A. Pseudomenstration.
- B. Positive Ortolani's test.
- C. Dermal melanosis.
- D. Gynecomastia.
Correct Answer: B
Rationale: A positive Ortolani's test indicates hip dysplasia, requiring intervention, unlike other benign findings.
A nurse is caring for a newborn who is at 34 weeks of gestation, weighs 1,550 g, and has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator for which of the following reasons?
- A. The newborn's temperature control mechanism is immature.
- B. Heat increases the flow of oxygen to the newborn's extremities.
- C. The newborn has a small body surface for his weight.
- D. Heat facilitates the drainage of mucus for a premature newborn.
Correct Answer: A
Rationale: Premature newborns have immature thermoregulation, making an incubator essential to maintain body temperature and prevent cold stress.
A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?
- A. Cephalhematoma.
- B. Nevus flammeus.
- C. Caput succedaneum.
- D. Molding.
Correct Answer: A
Rationale: Cephalhematoma is swelling confined by suture lines, distinguishing it from caput succedaneum, which crosses them.