Nokea
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?
- A. Place child in an isolette.
- B. Administer oxygen.
- C. Swaddle baby in a blanket.
- D. Apply pulse oximeter.
Correct Answer: C
Rationale: Cyanosis in extremities is normal in the first few hours due to peripheral vasoconstriction; swaddling provides warmth without unnecessary intervention.
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It is time for a baby who is in the drowsy behavioral state to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select one that doesn't apply
- A. Swaddle or tightly bundle the baby.
- B. Hand express milk onto the baby's lips.
- C. Talk with the baby while making eye contact.
- D. Remove the baby's shirt and change the diaper.
Correct Answer: A
Rationale: Stimulating the baby with milk, voice, or tactile changes can encourage feeding.
The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?
- A. No swelling or edema to the perineal area
- B. Patient complains that the sitz bath is too col
- C. Patient reports she took two sitz baths in 12 hours.
- D. Edges of the perineal laceration are well approximate
Correct Answer: A
Rationale: The correct answer is A because the absence of swelling or edema to the perineal area indicates that the ice sitz baths have been effective in reducing inflammation and promoting healing. Swelling and edema are common postpartum, and the use of ice sitz baths can help reduce these symptoms.
Choice B is incorrect because the patient complaining that the sitz bath is too cold does not provide information on the effectiveness of the treatment, only the patient's comfort level.
Choice C is incorrect because the frequency of sitz baths does not necessarily indicate effectiveness. It is more important to assess the outcomes of the treatment rather than the number of baths taken.
Choice D is incorrect because the approximation of perineal laceration edges may be influenced by other factors such as suturing technique, rather than the effectiveness of the ice sitz baths.
A family is concerned about how their 2-year-old son is going to react to the new baby. Which intervention would help facilitate sibling attachment?
- A. Have the mother and father spend individual time with their son to allay potential anxiety over the new baby coming in and displacing his position in the family as the only child.
- B. Make sure that their son is supervised at all times when the baby is brought home
- C. Include the son in helping to take care of the baby and reinforce the label of “big brother” as a special role.
- D. Observe the son’s reaction to the baby and let him decide when he wants to be
Correct Answer: C
Rationale: The correct answer is C because involving the 2-year-old son in caring for the new baby and reinforcing his role as a "big brother" can help facilitate sibling attachment. This intervention promotes bonding, fosters a sense of responsibility, and helps the son feel included in the family dynamic. It also allows the son to feel special in his new role, leading to positive feelings towards the new baby.
Choice A is incorrect as just spending individual time with the son may not address his concerns about the new baby and could potentially reinforce any feelings of displacement. Choice B is incorrect as constant supervision may not necessarily facilitate sibling attachment and could lead to feelings of restriction or resentment. Choice D is incorrect as it puts the onus solely on the son without providing clear guidance or support in navigating the new family dynamic.
A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding?
- A. The mother states,"I'm so tired. Please feed the baby in the nursery for me."
- B. The mother states,"Her eyes look like mine, but her chin is her Dad's."
- C. The mother says,"We have decided to name her Sarah after my mother."
- D. The mother says,"I breastfed her. I still need help swaddling her, though."
Correct Answer: A
Rationale: Avoidance of infant care suggests bonding issues.
What is the term for the separation found in the midline of the abdomen after birth?
- A. uterine subinvolution
- B. umbilical hernia
- C. striae
- D. diastasis recti abdominus
Correct Answer: D
Rationale: The correct answer is D: diastasis recti abdominus. This term refers to the separation of the rectus abdominis muscles along the midline of the abdomen. This condition commonly occurs after pregnancy due to the stretching of the abdominal muscles. It is important to differentiate diastasis recti from other conditions such as uterine subinvolution, which is the delayed return of the uterus to its normal size postpartum; umbilical hernia, which is a protrusion of abdominal contents through the umbilical ring; and striae, which are stretch marks caused by rapid stretching of the skin. Diastasis recti is characterized by a visible gap between the muscles, often causing a bulge in the midline of the abdomen. Treatment usually involves specific exercises to strengthen the abdominal muscles and improve the condition.