Nokea
A nursing student is measuring a newborn babys head circumference. Which action by the student demonstrates good understanding of this procedure?
- A. Measures three times records the average
- B. Places tape measure at the hair line
- C. Records the largest of three measurements
- D. Uses two finger-breadths to estimate size
Correct Answer: C
Rationale: The student should measure the infants head three times and record the largest of the three measurements. The other actions are incorrect; the student should not use the average
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What is a routine health provider visiting schedule for a newborn in their first year of life, beginning at 1 month of age?
- A. 1 month, 2 months, 4 months, 6 months, 9 months, and 12 months of age
- B. 1 month to 12 months, visiting once each month
- C. 1 month, 3 months, 6 months, 9 months, and 12 months
- D. 1 month, 3 months, 6 months, 12 months
Correct Answer: A
Rationale: Routine visits occur at 1, 2, 4, 6, 9, and 12 months.
Which woman is most likely to continue breastfeeding beyond 6 months?
- A. A woman who avoids using bottles.
- B. A woman who uses formula for every other feeding.
- C. A woman who offers water or formula after breastfeeding.
- D. A woman whose infant is satisfied for 4 hours after the feeding.
Correct Answer: A
Rationale: The correct answer is A because avoiding bottles helps maintain the baby's preference for breastfeeding, leading to a higher likelihood of continuing beyond 6 months. Using formula for every other feeding (choice B) introduces a different feeding method, potentially reducing breastfeeding duration. Offering water or formula after breastfeeding (choice C) can reduce the baby's interest in breastfeeding exclusively. A satisfied baby for 4 hours after feeding (choice D) does not necessarily indicate a longer breastfeeding duration as other factors like feeding frequency play a role.
Which statement is most accurate regarding delivery of a newborn?
- A. Infants delivered via cesarean section are at lower risk of transitional problems.
- B. Vaginal deliveries increase the risk of infants aspirating lung fluid.
- C. Cesarean deliveries do not allow for thoracic squeeze of fluid.
- D. Vaginal deliveries are often avoided in term infants.
Correct Answer: C
Rationale: The correct answer is C. Cesarean deliveries do not allow for thoracic squeeze of fluid. During vaginal delivery, the infant's thorax undergoes a squeezing motion which helps to expel the amniotic fluid from the lungs, reducing the risk of respiratory issues. In contrast, infants delivered via cesarean section do not experience this thoracic squeeze, potentially leading to a higher risk of respiratory problems.
A is incorrect because infants delivered via cesarean section may actually have higher risks of transitional problems due to the lack of thoracic squeeze. B is incorrect as vaginal deliveries facilitate the natural process of clearing lung fluid. D is incorrect as vaginal deliveries are the preferred method for term infants when possible, as they provide various benefits for both the mother and the baby.
The nurse is assessing an infant's extrusion reflex. To perform this correctly, what steps does the nurse take?
- A. Place a small object in the infant's hand.
- B. Stroke the side of the infant's cheek.
- C. Touch the tip of the infant's tongue.
- D. Turn the infant's head to one side.
Correct Answer: C
Rationale: The extrusion reflex is elicited by touching the tip of the infant's tongue. The tongue should protrude outward. Palmar grasp is detected by placing a small object in the infant's hand. Stroking the side of the cheek should result in the rooting reflex. Turning the head and watching the position of the extremities is part of the tonic neck or fencing reflex.
Transient tachypnea of the neonate develops due to what pathophysiologic phenomenon?
- A. failure to clear lung fluid by the usual mechanism
- B. failure of the patent ductus arteriosus to close
- C. insufficient surfactant production
- D. aspiration of meconium during vaginal or cesarean birth that interferes with surfactant activity
Correct Answer: A
Rationale: The correct answer is A because transient tachypnea of the neonate is primarily caused by the failure to clear lung fluid by the usual mechanism. During birth, the baby may not expel the lung fluid properly, leading to respiratory distress. This results in rapid breathing (tachypnea) due to the retained fluid in the lungs. The other choices are incorrect as they do not directly relate to the pathophysiology of transient tachypnea. Choice B involves the heart (patent ductus arteriosus), choice C relates to insufficient surfactant production seen in respiratory distress syndrome, and choice D mentions meconium aspiration syndrome, which is a different condition caused by the aspiration of meconium into the lungs, not related to the failure to clear lung fluid.