Nokea
A student nurse is caring for an infant who was just circumcised. What assessment finding should the student report to the registered nurse?
- A. No voiding for 8 hours
- B. Slight blood on the diaper
- C. Swelling on the glans penis
- D. Wishes to be held continuously
Correct Answer: A
Rationale: The nurse should assess for the first voiding after a circumcision to evaluate for urinary obstruction related to injury or swelling. Slight blood on the diaper would be expected. Some swelling may occur and does not cause concern unless it blocks the urethra. After a procedure, it is normal for an infant to wish to be held and comforted.
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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 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.
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.
A nurse is planning discharge needs to a family whose baby has just been born. Which statement is the most accurate regarding care of the umbilical cord?
- A. Wash the newborn every day in a shallow tub of water.
- B. Rinse the umbilical cord with water and soap until it falls off.
- C. Notify the practitioner if the umbilical cord is still in place after 1 week.
- D. Swab the umbilical cord with alcohol or water daily until it falls off.
Correct Answer: D
Rationale: The correct answer is D. Swabbing the umbilical cord with alcohol or water daily until it falls off is the recommended care to prevent infection. Alcohol helps dry out the cord stump, promoting faster healing.
- A: Washing the newborn every day in water can introduce bacteria and moisture to the cord, increasing infection risk.
- B: Using soap on the umbilical cord can irritate the skin and delay healing.
- C: It's normal for the umbilical cord to fall off within 1-2 weeks, so there's no need to notify the practitioner unless there are signs of infection.
The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? (Select all that apply.)
- A. Testes are pendulous, and the scrotum has deep rugae
- B. Plantar creases over entire sole
- C. Lanugo abundant over shoulders and back
- D. Vernix well distributed over entire body
Correct Answer: A
Rationale: Full-term infants typically exhibit pendulous testes, deep scrotal rugae, and plantar creases over the entire sole. Lanugo is usually minimal, and vernix tends to be localized rather than widespread.