An infant has just been admitted to the newborn nursery after an uncomplicated delivery. Upon assessment, the nurse notes poor muscle tone and a temperature of 96°F axillary. What is the next course of action?
- A. Obtain a blood glucose reading
- B. Prepare for resuscitation needs
- C. Call for a transfer to the neonatal intensive care unit
- D. Place warm blankets around the newborn in the open crib
Correct Answer: A
Rationale: The correct next course of action is to obtain a blood glucose reading (Choice A). Poor muscle tone and low temperature in a newborn can be indicative of hypoglycemia, which is a common issue in infants. By checking the blood glucose level, the healthcare provider can determine if hypoglycemia is the cause of the symptoms. This action allows for prompt intervention if needed. Choices B, C, and D are incorrect as they do not address the potential underlying issue of hypoglycemia. Resuscitation needs (Choice B) should only be considered if the infant's condition deteriorates. Calling for a transfer to the neonatal intensive care unit (Choice C) may not be necessary if the issue can be managed in the nursery. Placing warm blankets (Choice D) may help with temperature regulation but does not address the root cause of the symptoms.
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What characteristics are directly related to the newborn's decreased ability to maintain thermal stability?
- A. A neonate has decreased subcutaneous fat and a large body surface-to-weight ratio.
- B. The blood vessels in the neonate are farther from the skin than those of an adult.
- C. Newborns are unable to rely on brown adipose tissue for heat production.
- D. The newborn prefers to be in constant motion, increasing the surface area exposed to the environment.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Subcutaneous fat provides insulation, so decreased fat leads to heat loss.
2. A larger body surface-to-weight ratio means more heat loss through the skin.
3. Both factors contribute to the newborn's decreased ability to maintain thermal stability.
4. Blood vessels being farther from the skin (choice B) does not impact thermal stability directly.
5. Brown adipose tissue (choice C) is actually important for heat production in newborns.
6. Constant motion (choice D) may increase heat loss but is not a primary factor in thermal stability for newborns.
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: A
Rationale: The Apgar score evaluates the newborn's neurological and physical condition immediately after birth.
The nurse is providing care for a neonate during the fourth stage of labor. Which action does the nurse take during this stage?
- A. Dry the neonate immediately.
- B. Compete neonate assessment within 1 hour.
- C. Obtain neonate blood glucose levels.
- D. Perform Apgar screening until scores are 7.
Correct Answer: A
Rationale: The correct answer is A: Dry the neonate immediately. This is crucial during the fourth stage of labor to prevent hypothermia in the neonate. Drying the neonate helps maintain body temperature and reduce heat loss. Choice B is incorrect because a complete neonate assessment should be done within the first 1-2 minutes, not within 1 hour. Choice C is incorrect as obtaining neonate blood glucose levels is not typically done during the immediate post-birth period unless indicated. Choice D is incorrect as Apgar screening is typically done at 1 and 5 minutes after birth, not until the scores are 7.
A new mother and father are inspecting their baby after the nurse brings the infant to them. The mother wants to know why her baby has bruises on the buttocks area. Which statement should be made by the nurse?
- A. Bruises are common after a traumatic delivery. I will ask the physician to come discuss the delivery.'
- B. These areas are called blue/gray macules and are common in certain ethnic groups, but will disappear around 3 years of age.'
- C. These are not bruises; these spots are birthmarks and are usually a permanent impairment.'
- D. The previous nurse did not report these findings. Who else has been in the room with the baby?'
Correct Answer: B
Rationale: The correct answer is B because blue/gray macules, also known as Mongolian spots, are common in certain ethnic groups, especially in babies with darker skin tones. These marks typically appear on the buttocks and lower back and usually fade away by around 3 years of age. This explanation reassures the parents that the marks are not bruises from trauma but rather a normal and harmless skin pigmentation variation.
Choices A, C, and D are incorrect because:
A: This statement implies a traumatic delivery, which may cause unnecessary worry for the parents. It also deflects responsibility by suggesting involving the physician without providing a clear explanation.
C: This statement misidentifies the marks as birthmarks, which are different from Mongolian spots. It also incorrectly suggests they are a permanent impairment, causing unnecessary concern.
D: This statement is confrontational and shifts the focus away from addressing the parents' concerns. It does not provide any explanation or reassurance about the baby's condition.
Which assessment finding of a newborn in the newborn nursery warrants further investigation and notification to the physician?
- A. Absent bowel sounds 15 minutes after delivery
- B. Bluish discoloration on the buttocks area
- C. Regurgitation of small amounts of feedings
- D. Absent meconium stool on day 2 of life
Correct Answer: D
Rationale: The correct answer is D because the absence of meconium stool on day 2 of life can indicate a potential intestinal obstruction, which requires immediate medical attention. Meconium should be passed within the first 24-48 hours of life. A: Absent bowel sounds 15 minutes after delivery are normal as the gastrointestinal system may take some time to start functioning. B: Bluish discoloration on the buttocks area can be due to vascular changes and is usually not concerning. C: Regurgitation of small amounts of feedings is common in newborns and often not indicative of a serious issue.