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A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?
- A. “The cause might be too short or infrequent feedings.”
- B. “It is due to the newborn’s loss of the influence of the maternal hormones.”
- C. “This might be related to your baby having 3 stools a day.”
- D. “You might want to offer water supplements between feedings.”
Correct Answer: A
Rationale: The correct answer is A because insufficient feeding can lead to excessive weight loss in newborns. Frequent and effective breastfeeding helps ensure the baby receives enough milk and nutrients. Option B is incorrect as maternal hormones do not directly affect newborn weight loss. Option C is incorrect as the number of stools is not necessarily indicative of weight loss. Option D is incorrect as newborns should only be fed breastmilk or formula, not water supplements.
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A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?
- A. Drying the newborn’s skin thoroughly.
- B. Preventing air drafts.
- C. Placing the newborn on a warm surface.
- D. Maintaining ambient room temperature at 24°C (75.2°F).
Correct Answer: A
Rationale: The correct answer is A: Drying the newborn's skin thoroughly. When a newborn is born, they are wet and evaporative heat loss occurs as the moisture on their skin evaporates, leading to cooling. Drying the newborn's skin thoroughly helps reduce this heat loss by preventing the moisture from evaporating. Preventing air drafts (B) and placing the newborn on a warm surface (C) can help with overall thermal regulation but do not specifically target evaporative heat loss. Maintaining ambient room temperature at 24°C (75.2°F) (D) is important for thermoregulation but does not directly address evaporative heat loss.
A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?
- A. It detects Rh-positive antibodies in the mother’s blood.
- B. It determines the presence of maternal antibodies in the newborn’s blood.
- C. It detects Rh-negative antibodies in the newborn’s blood.
- D. It determines if kernicterus will occur in the newborn.
Correct Answer: A
Rationale: The correct answer is A because the indirect Coombs test detects Rh-positive antibodies in the mother's blood. In Rh incompatibility, Rh-negative mothers can develop antibodies against Rh-positive fetal blood, which can lead to hemolytic disease of the newborn. This test helps identify the presence of these antibodies to prevent harm to the newborn. Choice B is incorrect because the test is done on the mother's blood, not the newborn's. Choice C is incorrect as it refers to the wrong blood type. Choice D is incorrect as kernicterus is related to severe jaundice, not Rh incompatibility.
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- A. Cover the cord with a sterile, moist saline dressing.
- B. Place the client in knee-chest position.
- C. Prepare the client for an immediate birth.
- D. Insert a gloved hand into the vagina to relieve pressure on the cord.
Correct Answer: D
Rationale: The correct answer is D: Insert a gloved hand into the vagina to relieve pressure on the cord. This is the priority action in this situation to prevent cord compression, which can compromise fetal blood flow. By gently elevating the presenting part off the cord, the nurse can help restore blood flow to the baby. Covering the cord (A) or placing the client in the knee-chest position (B) are not as effective in relieving pressure on the cord. Preparing for an immediate birth (C) may be necessary but addressing the cord issue is the priority.
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother’s room. Which of the following is an appropriate response by the nurse?
- A. You can push the baby to the room in a wheeled bassinet.
- B. If you show me your photo identification, you can take the infant.
- C. Have the mother ring, and I will take the baby to the room.
- D. You may carry your grandchild to the room.
Correct Answer: C
Rationale: The correct response is C: Have the mother ring, and I will take the baby to the room. This is the appropriate response because it ensures the safety and security of the newborn by confirming the mother's approval before allowing the grandmother to take the baby to the room. This step is crucial to prevent any unauthorized individuals from taking the baby without the mother's consent.
Choice A is incorrect because pushing the baby to the room in a wheeled bassinet may not involve verifying the mother's consent. Choice B is incorrect as asking for photo identification does not confirm the mother's approval. Choice D is incorrect as it assumes the grandmother can carry the baby without checking with the mother first.
In summary, choice C is the correct response as it prioritizes the safety and well-being of the newborn by ensuring the mother's consent is obtained before allowing the grandmother to take the baby to the room.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
- A. This is a cephalohematoma which can occur spontaneously.
- B. A caput succedaneum will subside in a few days.
- C. Mongolian spots can be found on the skin of many newborns.
- D. This is a telangiectatic nevus and no treatment is needed.
Correct Answer: B
Rationale: The correct answer is B: A caput succedaneum will subside in a few days. A caput succedaneum is a diffuse swelling of the scalp that occurs due to pressure on the baby's head during labor. It typically resolves on its own within a few days. In this scenario, since the swelling crosses the suture line, it is likely a caput succedaneum. Palpation of the swelling helps to differentiate it from cephalohematoma, which is confined by suture lines. Choice A is incorrect because a cephalohematoma is a collection of blood between the periosteum and skull bone, not the same as caput succedaneum. Choices C and D are incorrect as they refer to different conditions unrelated to the swelling on the newborn's head.