Nokea
A nurse is preparing to discharge an infant who has developmental dysplasia of the hip (DDH). What discharge instruction would be most important?
- A. How to correctly perform Ortolani's maneuver
- B. How to properly use the Pavlik harness
- C. When to return for corrective surgery
- D. Where to take the baby to be fit for corrective shoes
Correct Answer: B
Rationale: A baby with DDH will be placed in a special splint, most often the Pavlik harness, to keep the legs in a position of abduction. The harness is worn continuously for 3-6 months, during which time bone growth helps create a normal hip joint. Ortolani's maneuver is an assessment for DDH. Surgery may be required, but not until it has been determined that bone growth is not creating a normally shaped hip joint. Corrective shoes are not needed.
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The nurse is assigned to the postpartum room of a 12-hour-old neonate, and the EHR has a task reminder prompting the nurse to complete a Brazelton assessment on the newborn. Why is this not appropriate?
- A. This newborn has been born to a person who is placing the infant up for adoption.
- B. This newborn has been born to a person who birthed by cesarean section.
- C. This newborn is only 12 hours old.
- D. This newborn is experiencing pathologic jaundice.
Correct Answer: C
Rationale: The Brazelton Neonatal Behavioral Assessment Scale is typically performed after 24–48 hours of life.
In preparing a family for discharge from the perinatal unit, which method of nail care does the nurse teach as the preferred method?
- A. Cutting the nails with sharp scissors
- B. Filing the nails with a fine emery board
- C. Letting the nails break off naturally
- D. Wrapping the infant's hands in mittens
Correct Answer: B
Rationale: Several options exist for nail care to keep the infant from scratching her face. The nails can be cut, but there is a risk of damaging the delicate skin around the nail. This is best done while the baby sleeps. Letting the nails break off is not a good option, as the child may injure herself before they break. Covering the hands with mittens or a tee shirt is a possible option, but does not allow the child to suck on the fingers for self-soothing. The best option is to file the nails gently with a fine-grained emery board.
An infant with a congenital cardiac disorder is receiving postsurgical palliation and nearing time for discharge. What findings would be indicators that the infant is ready for discharge?
- A. The infant is medically ready, has had all routine discharge screenings, and is up to date on their vaccinations.
- B. The home caregiver has not been able to come to the hospital and has not received either CPR or needed NG tube training.
- C. The respiratory therapist has done a home evaluation, which showed the home environment was appropriate, but the DME has not shipped the ventilator or oxygen delivery equipment.
- D. The infant is escalating on oxygen requirements and unable to maintain their temperature between 36.6° C and 38° C.
Correct Answer: A
Rationale: Medical readiness, completed screenings, and up-to-date vaccinations indicate discharge readiness.
The nurse is performing the initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system?
- A. Respiratory
- B. Cardiovascular
- C. Gastrointestinal
- D. Musculoskeletal
Correct Answer: A
Rationale: The correct answer is A: Respiratory. Retractions, nasal flaring, and tachypnea are signs of respiratory distress in a newborn. The nurse should focus on the respiratory system to assess the baby's breathing, lung sounds, oxygen saturation, and overall respiratory status. This is crucial for identifying any potential respiratory issues and providing prompt interventions.
Choices B, C, and D are incorrect because the symptoms described are specific to respiratory distress and do not indicate cardiovascular, gastrointestinal, or musculoskeletal issues. Focusing on these systems would not address the immediate concern of respiratory distress in the newborn.
The nurse completes an initial newborn examination. The nurses findings include the following: heart rate 136 beats/minute; respiratory rate 64 breaths/minute; temperature 98.2F (36.8C). The nurse also documents a heart murmur,absence of bowel sounds symmetry of ears and eyes no grunting or nasal flaring and full range of movement of all extremities. Which finding requires immediate consultation with the health-care provider?
- A. Absent bowel sounds
- B. Heart murmur
- C. Respiratory rate
- D. Temperature
Correct Answer: A
Rationale: Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small