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A nurse is assisting in the care of a newborn born 1 hr ago who was delivered at 38 weeks of gestation. Which action should the nurse take first?
- A. The nurse should first report the client's laboratory results to the primary health care.
- B. The nurse should first report the client's respiratory status to the primary health care.
- C. The nurse should first report the client's brachial pulses to the primary health care.
Correct Answer: B
Rationale: Reporting respiratory status is urgent in respiratory distress syndrome, guiding immediate interventions.
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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.
A nurse is reviewing the laboratory results of a newborn that is 4 hr old. Which of the following findings should the nurse identify as the priority?
- A. Bilirubin 18 mg/dL.
- B. Hemoglobin 22 g/dL.
- C. Blood glucose 50 mg/dL.
- D. Platelets 200,000/mm³.
Correct Answer: A
Rationale: A bilirubin of 18 mg/dL at 4 hours indicates severe hyperbilirubinemia, risking brain damage if untreated.
What are the newborn vital sign ranges? Select all that apply.
- A. Temperature 97.7-99.3 axillary.
- B. Heart rate asleep 100 bpm, 120-160 bpm, crying: 180 bpm.
- C. Blood pressure not routinely assessed.
- D. Respiratory rate 30-60 breaths per minute.
Correct Answer: A,B,C,D
Rationale: Newborn vital signs include axillary temperature 97.7-99.3°F, heart rate 100-180 bpm depending on state, respiratory rate 30-60/min, and blood pressure not routinely measured.
A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching?
- A. I won't wear a bra during the daytime.
- B. I'll apply cold compresses 20 min before each feeding.
- C. I'll feed my baby every 2 hours.
- D. I will stop breastfeeding until I am done with the antibiotics.
Correct Answer: C
Rationale: Frequent feeding every 2 hours prevents and relieves engorgement by ensuring milk removal.
A nurse is reinforcing discharge teaching about circumcision care with the parent of a newborn who had a circumcision using the Plastibell device. Which of the following client statements indicates an understanding of the teaching? Select all that apply.
- A. I'll wash his penis with warm water and mild soap each day.
- B. I'll make sure his diaper is loose in the front.
- C. I expect the plastic ring to fall off by itself within a week.
- D. I'll apply petroleum jelly to his penis during diaper changes.
- E. I'll call the doctor if bleeding occurs after the ring falls off.
Correct Answer: C,E
Rationale: The Plastibell ring falls off within a week, and bleeding post-falloff requires medical attention, indicating proper care understanding.