Nokea
An 8-pound 15-ounce baby born at 35 weeks’ gestation would be described using which terminology? Select all that apply.
- A. Small for gestational age
- B. Term
- C. Preterm
- D. Average for gestational age
- E. Post term
Correct Answer: C,D
Rationale: The correct answer is C and D. Choice C, "Preterm," is correct because a baby born at 35 weeks' gestation is considered preterm, as full term is typically around 39-40 weeks. Choice D, "Average for gestational age," is also correct because the baby's weight falls within the normal range for babies born at 35 weeks. Choice A, "Small for gestational age," is incorrect as the baby's weight is appropriate for its gestational age. Choice B, "Term," is incorrect because 35 weeks is considered preterm. Choice E, "Post term," is incorrect as it refers to a baby born after 42 weeks' gestation.
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A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?
- A. Reddened with a small amount of bloody drainage.
- B. Pink without drainage.
- C. Reddened with a scant amount of yellow exudate.
- D. Reddened, with copious blood.
Correct Answer: C
Rationale: The correct answer is C: Reddened with a scant amount of yellow exudate. After circumcision, it is normal for the surgical site to appear reddened due to the inflammatory response. The presence of a scant amount of yellow exudate indicates normal wound healing with minimal discharge. This is a sign of the body's natural process of cleansing the wound. Choices A and D are incorrect because copious blood or bloody drainage would be abnormal and may indicate bleeding complications. Choice B is incorrect as pink without drainage would not be expected immediately after circumcision. In choice A, while some bloody drainage may be expected, the presence of yellow exudate is more indicative of normal healing.
A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?
- A. “The cause might be too short or infrequent feedings.”
- B. “It is due to the newborn’s loss of the influence of the maternal hormones.”
- C. “This might be related to your baby having 3 stools a day.”
- D. “You might want to offer water supplements between feedings.”
Correct Answer: A
Rationale: The correct answer is A because insufficient feeding can lead to excessive weight loss in newborns. Frequent and effective breastfeeding helps ensure the baby receives enough milk and nutrients. Option B is incorrect as maternal hormones do not directly affect newborn weight loss. Option C is incorrect as the number of stools is not necessarily indicative of weight loss. Option D is incorrect as newborns should only be fed breastmilk or formula, not water supplements.
A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?
- A. Place a finger at the base of the newborn’s toes.
- B. Turn the newborn’s head quickly to one side.
- C. Hold the newborn vertically allowing one foot to touch the table surface.
- D. Perform a sharp hand clap near the infant.
Correct Answer: D
Rationale: The Moro reflex is a startle reflex observed in newborns. To elicit this reflex, a sudden loud noise or movement is needed. Performing a sharp hand clap near the infant is the appropriate action to trigger the Moro reflex. This action mimics a sudden loud noise, causing the baby to extend the arms and legs, then bring them back in a hugging motion. Placing a finger at the base of the newborn's toes (Choice A) does not elicit the Moro reflex. Turning the newborn's head quickly to one side (Choice B) triggers the asymmetric tonic neck reflex, not the Moro reflex. Holding the newborn vertically allowing one foot to touch the table surface (Choice C) elicits the stepping reflex, not the Moro reflex.
A nurse in a provider’s office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?
- A. It assists in identifying the location of the placenta and fetus.
- B. It is useful for estimating fetal age.
- C. This is a screening tool for spina bifida.
- D. This will determine if there is more than one fetus.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Prior to amniocentesis, an ultrasound is done to identify the location of the placenta and fetus. This is crucial to ensure the safety of the procedure. It helps in determining the best site for needle insertion to avoid harming the fetus or placenta. Additionally, it allows for visualization of any abnormalities that could affect the amniocentesis procedure.
Summary of other choices:
B: Estimating fetal age is not the primary purpose of the ultrasound before amniocentesis.
C: Screening for spina bifida is usually done through other specific tests, not the ultrasound before amniocentesis.
D: Determining if there is more than one fetus is not the main goal of the ultrasound before amniocentesis.
A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care?
- A. Monitor blood glucose levels.
- B. Monitor intake and output.
- C. Monitor weight.
- D. Monitor axillary temperature.
Correct Answer: A
Rationale: The correct answer is A: Monitor blood glucose levels. Newborns who are small for gestational age (SGA) are at risk for hypoglycemia due to inadequate glycogen stores. Monitoring blood glucose levels is crucial to detect and manage hypoglycemia promptly. Monitoring intake and output (B) is important but not the priority in this case. Monitoring weight (C) is essential for assessing growth but does not directly address the immediate risk of hypoglycemia. Monitoring axillary temperature (D) is important for detecting infection or hypothermia but does not address the specific needs of an SGA newborn.