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A patient with blood group AB, whose husband has blood group O, has recently given birth. What is the main complication or test result to watch for in the newborn concerning ABO incompatibility?
- A. negative Coombs test
- B. bleeding from the nose and ear
- C. jaundice after the first 24 hours of life
- D. jaundice within the first 24 hours of life
Correct Answer: D
Rationale: Jaundice appearing within the first 24 hours suggests ABO incompatibility.
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The Apgar assessment tells the nurses and clinicians on the labor and delivery unit what information about the newborn?
- A. The Apgar assessment and score tells the team how the newborn is doing neurologically and physically after the birth.
- B. The Apgar assessment and score predicts the newborn's overall morbidity and mortality moving forward after birth.
- C. The Apgar assessment and score tells the team how the newborn is transitioning to the extrauterine world after birth.
- D. The Apgar assessment and score tells the team how the newborn handled the birth overall.
Correct Answer: C
Rationale: Rationale: The correct answer is C because the Apgar assessment and score specifically evaluate how well the newborn is transitioning to the outside world after birth. The Apgar score assesses the newborn's heart rate, respiratory effort, muscle tone, reflex irritability, and color. These parameters provide crucial information about the baby's initial adaptation to life outside the womb. Option A is incorrect because it oversimplifies the assessment by focusing only on neurological and physical aspects. Option B is incorrect because the Apgar score is not intended to predict long-term morbidity and mortality. Option D is incorrect as it does not encompass the full scope of the Apgar assessment, which is primarily concerned with the immediate transition of the newborn to extrauterine life.
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.
A mother worries about her infant feeling pain during a heel stick for a blood test. What action by the nurse is best?
- A. Encourage breastfeeding during the heel stick.
- B. Ice the infants heel prior to the blood draw.
- C. Massage the infants heel after the needle stick.
- D. Reassure the mother that infants dont feel pain.
Correct Answer: A
Rationale: Infants feel pain and remember painful procedures. Breastfeeding has been shown to be an effective
The nurse notes swelling in the scrotum of a newborn infant. Transillumination reveals a reddish-yellow reflection. What action by the nurse is best?
- A. Document the findings and reassure the parents.
- B. Elevate the scrotum and apply ice for 20 minutes.
- C. Notify the health-care provider immediately.
- D. Obtain informed consent for emergent surgery.
Correct Answer: A
Rationale: When the nurse assesses a swollen scrotum, it is important to determine that the scrotal sac does not contain entrapped bowel or a mass. Transillumination can determine the presence of a mass when the light directed at the scrotum does not produce a reflection. A reddish-yellow reflection indicates fluid, which will be reabsorbed on its own. The nurse should document the findings and reassure the parents. No further action is needed.
The nurse is assessing a newborn girl born at 40 weeks of gestation based on the parent's LMP. What assessment finding of the genitalia confirms this gestational age?
- A. labia majora covering clitoris and labia minora
- B. clitoris prominent, labia minora enlarged
- C. small labia minora, clitoris enlarged
- D. labia majora enlarged, labia minora small
Correct Answer: A
Rationale: The correct answer is A because at 40 weeks of gestation, the labia majora should completely cover the clitoris and labia minora. This is known as the "laboratory majora sign" and is characteristic of full-term newborns.
Choice B is incorrect because a prominent clitoris and enlarged labia minora indicate a younger gestational age, typically around 36-38 weeks.
Choice C is incorrect as small labia minora and enlarged clitoris suggest a preterm newborn, around 32-34 weeks.
Choice D is incorrect as enlarged labia majora and small labia minora are more indicative of a post-term newborn, around 42 weeks or more.
Overall, the correct answer, choice A, aligns with the expected genitalia findings for a newborn born at 40 weeks of gestation based on the parent's LMP.