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A nurse is beginning a newborns physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best?
- A. Ask the mother to attempt to breastfeed the infant.
- B. Conduct the assessment quickly then swaddle the baby.
- C. Increase the heat in the room so the baby wont get chilled.
- D. Postpone the assessment until the infant has calmed.
Correct Answer: D
Rationale: An infant who seems irritable and overreacts to voices
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The nurse teaching a family about bonding with their infant describes touch as an important facet of this process. What does the nurse understand is most important about touch and bonding?
- A. All newborn care must be completed through touch.
- B. Parental recognition occurs through touch.
- C. The neonate learns exclusively through touch.
- D. Touch accustoms the parent to the infant's body.
Correct Answer: C
Rationale: All options are at least partially correct. However, the most important point about touch and bonding is that all the infant learns during the neonatal period is conveyed through touch. Touch conveys warmth, love, pleasure, comfort, and security to the neonate.
A term infants initial blood glucose level is 42 mg/dL. What action by the nurse is most appropriate?
- A. Document the findings in the infants chart.
- B. Encourage the mother to initiate breastfeeding.
- C. Prepare to administer intravenous glucose.
- D. Recheck the blood glucose in 2 hours.
Correct Answer: A
Rationale: For term infants
The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark?
- A. A
- B. B
- C. C
- D. D
Correct Answer: C
Rationale: The correct answer is C because nevus flammeus, also known as a port-wine stain, is a flat, pink, or red birthmark that appears as a patch on the skin. Choice C depicts a birthmark that matches this description. Choice A shows a mole, choice B shows a café-au-lait spot, and choice D shows a strawberry hemangioma, which are different types of birthmarks. So, choice C is the only one that accurately represents a nevus flammeus birthmark.
A mother brings her 4-week-old newborn into the clinic for a well-child check. She reports to the nurse that the newborn developed small white marks on her nose. What are these small white marks commonly called?
- A. Milia
- B. Mongolian spots
- C. Erythema toxicum
- D. Port-wine stain
Correct Answer: A
Rationale: The correct answer is A: Milia. Milia are tiny, white, pearly bumps that commonly appear on a newborn's face, including the nose, due to blocked oil glands. They are harmless and typically disappear on their own.
Explanation:
1. Milia are common in newborns, appearing as small white bumps on the nose and face.
2. They result from blocked oil glands and are not harmful.
3. Mongolian spots are bluish-gray birthmarks usually on the lower back or buttocks.
4. Erythema toxicum presents as red blotches on the skin shortly after birth.
5. Port-wine stain is a vascular birthmark that appears as a pink or red mark on the skin.
The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice?
- A. Mongolian spots
- B. Molding
- C. Cephalohematoma
- D. Telangiectatic nevi
Correct Answer: C
Rationale: Cephalohematomas can cause breakdown of red blood cells, leading to increased bilirubin levels and jaundice.