Nokea
A nurse is assessing an infant who has a large bruise around his neck and face from a nuchal cord. What other assessment finding correlates with this condition?
- A. Elevated serum bilirubin
- B. Irritability with gentle handing
- C. Large-for-gestational-age measurements
- D. Obvious vertebral defects
Correct Answer: A
Rationale: Infants born with a nuchal cord often demonstrate significant bruising to the face and neck. This may be upsetting to the parents. Irritability with handling might be related to damage from birth trauma. Large-for-gestational-age infants often have bruising related to extraction techniques during a difficult birth. Obvious vertebral defects are associated with neural tube anomalies and can be seen in children with hairy pigmented skin lesions and hairy nevi located in the posterior midline area near the spinal column.
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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.
Which infant is not at risk for heat loss?
- A. Infant born at 38 weeks gestational age on a baby scale
- B. Preterm infant lying extended in the warmer
- C. Term infant who is lying in an open crib next to the door
- D. Infant born at 41 weeks swaddled in the open crib of the nursery
Correct Answer: D
Rationale: The correct answer is D because swaddling helps maintain the infant's body temperature by preventing heat loss. Swaddling creates a cocoon-like environment, reducing exposure to external factors. Choice A is incorrect because a baby scale does not provide warmth. Choice B is incorrect as the preterm infant is in an extended position, which increases heat loss. Choice C is incorrect as the term infant lying next to the door may experience drafts and heat loss.
The nurse is teaching a student nurse about some of the differences between a term and preterm infant. Which statement is most accurate?
- A. Infants born at 32 weeks gestational age have sufficient alveolar stability to maintain adequate lung expansion.
- B. Surfactant may need to be given to the infant born less than 34 to 36 weeks of age to assist with alveolar stability.
- C. Women with gestational diabetes have larger babies; therefore, there are fewer issues with lung maturity when born preterm.
- D. Mothers carrying multiples fetuses will increase the surfactant production naturally in utero.
Correct Answer: B
Rationale: The correct answer is B because infants born before 34 to 36 weeks gestational age may not have fully developed surfactant production, which is crucial for alveolar stability and lung expansion. Surfactant reduces surface tension in the alveoli, preventing their collapse. Without sufficient surfactant, preterm infants are at risk of respiratory distress syndrome.
Choice A is incorrect because infants born at 32 weeks may still have underdeveloped alveoli and insufficient surfactant production, leading to potential lung expansion issues.
Choice C is incorrect because the presence of gestational diabetes does not guarantee sufficient lung maturity in preterm infants. Lung maturity is more closely related to gestational age and surfactant production.
Choice D is incorrect because while carrying multiple fetuses can slightly increase surfactant production, it may not be sufficient for preterm infants born before 34 to 36 weeks, necessitating the need for exogenous surfactant administration.
The nurse knows that during the organizational process, the newborn won't be rated as exceptionally good if they do what?
- A. They will remain alert.
- B. They will be highly irritable and demonstrate mood swings.
- C. They will demonstrate self-soothing and quieting techniques.
- D. The newborn will shut down body responses to stimuli when drowsy.
Correct Answer: B
Rationale: The correct answer is B because a newborn being highly irritable and demonstrating mood swings is indicative of poor adaptability and self-regulation skills, which are factors considered in rating newborns. Being irritable and having mood swings can be signs of difficulty in self-soothing and adjusting to the environment, hence not meeting the criteria for being rated exceptionally good.
A: Remaining alert is generally a positive sign of responsiveness, so it wouldn't hinder the newborn from being rated as exceptionally good.
C: Demonstrating self-soothing and quieting techniques is a positive behavior that can contribute to a newborn being rated as exceptionally good.
D: Shutting down body responses to stimuli when drowsy is a normal physiological response and does not necessarily impact the newborn's rating as exceptionally good.
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.