Nokea
A term infants initial blood glucose level is 42 mg/dL. What action by the nurse is most appropriate?
- A. Document the findings in the infants chart.
- B. Encourage the mother to initiate breastfeeding.
- C. Prepare to administer intravenous glucose.
- D. Recheck the blood glucose in 2 hours.
Correct Answer: A
Rationale: For term infants
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Which of the following is an important consideration in positioning a newborn for breastfeeding?
- A. Placing the infant at nipple level facing the breast.
- B. Keeping the infant's head slightly lower than the body.
- C. Using the forefinger and middle finger to support the breast.
- D. Limiting the amount of areola the infant takes into the mouth.
Correct Answer: A
Rationale: The correct answer, A, is important because it ensures proper alignment for effective breastfeeding. Placing the infant at nipple level facing the breast helps the baby latch on correctly, promoting optimal milk transfer. Choice B is incorrect as the infant's head should be in line with the body to prevent swallowing issues. Choice C is incorrect because the fingers should support the breast underneath, not on top. Choice D is also incorrect as the baby should take in a sufficient amount of areola for a deep latch.
The nurse is assigned to the room of a 15-year-old person who gave birth to a newborn 72 hours ago. Why is this newborn a perfect candidate for the Brazelton assessment?
- A. This parent-newborn couplet is at risk for delayed attachment.
- B. The newborn is likely going home soon.
- C. The EHR is prompting her to do so.
- D. The infant is likely withdrawing from a substance.
Correct Answer: A
Rationale: Delayed attachment may occur in younger parents, making the Brazelton assessment valuable for evaluating bonding.
Which infant is not at risk for heat loss?
- A. Infant born at 38 weeks gestational age on a baby scale
- B. Preterm infant lying extended in the warmer
- C. Term infant who is lying in an open crib next to the door
- D. Infant born at 41 weeks swaddled in the open crib of the nursery
Correct Answer: D
Rationale: The correct answer is D because swaddling helps maintain the infant's body temperature by preventing heat loss. Swaddling creates a cocoon-like environment, reducing exposure to external factors. Choice A is incorrect because a baby scale does not provide warmth. Choice B is incorrect as the preterm infant is in an extended position, which increases heat loss. Choice C is incorrect as the term infant lying next to the door may experience drafts and heat loss.
A faculty member explains to a nursing student that the best way to prevent hemorrhage from injuries in a neonate is which of the following?
- A. Administer vitamin K1 phytonadione (AquaMEPHYTON).
- B. Handle the infant carefully while wearing soft gloves.
- C. Keep the infant swaddled in several layers of blankets.
- D. Teach the parents how to trim the babys fingernails.
Correct Answer: A
Rationale: AquaMEPHYTON is given to newborns to promote normal blood clotting. The infants intestinal tract is sterile at birth and does not have the bacteria needed to create vitamin K
A nurse is beginning a newborns physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best?
- A. Ask the mother to attempt to breastfeed the infant.
- B. Conduct the assessment quickly then swaddle the baby.
- C. Increase the heat in the room so the baby wont get chilled.
- D. Postpone the assessment until the infant has calmed.
Correct Answer: D
Rationale: An infant who seems irritable and overreacts to voices