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An infant was born with anencephaly and was taken immediately to the NICU. The parents are about to visit for the first time. What action by the nurse is most appropriate?
- A. Call the hospital chaplain to visit the parents.
- B. Obtain informed consent for emergency surgery.
- C. Prepare the parents for how the infant will look.
- D. Show the parents proper gowning and gloving.
Correct Answer: C
Rationale: Infants born with anencephaly (incomplete closure of the anterior portion of the neural tube) are often missing parts of the brain, forehead, skull, and occiput. The nurse must be very sensitive in working with the parents of such children and needs to prepare the parents for how the child will look. Well-prepared parents have a better chance of being able to bond with their child. A visit from the chaplain may or may not be welcomed. Emergency surgery is not performed. Proper gowning and gloving are not needed unless the infant is in isolation.
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The most effective time to initiate breast-feeding is in which stage of reactivity for the neonate?
- A. period of decreased reactivity
- B. first period of reactivity
- C. second period of reactivity
- D. after the end of the second period of reactivity
Correct Answer: B
Rationale: The correct answer is B: first period of reactivity. During this stage, the infant is alert and eager to suckle, making it an optimal time to initiate breastfeeding. The infant's sucking reflex is strong, and they are more likely to latch on successfully. The other choices are incorrect because during the period of decreased reactivity (A), the infant is often drowsy and less interested in feeding. The second period of reactivity (C) may involve increased activity and may not be the best time to introduce breastfeeding. After the end of the second period of reactivity (D), the infant may be more settled and not as ready to breastfeed as during the first period of reactivity.
Edward, a newborn delivered at 41 weeks' gestation, weighs 10 lb 4 oz. Vaginal delivery for this G1P1 mother was assisted with forceps. The nurse is completing her assessment and notes a sharply demarcated swelling over the parietal bones. The occipital and frontal skull bones are not affected. The neck does not appear edematous and is soft to the touch with full mobility. The infant is awake and active and has been breast-feeding well. What is the most probable cause of the swelling?
- A. cephalohematoma
- B. subgaleal hemorrhage
- C. caput succedaneum
- D. skull fracture
Correct Answer: A
Rationale: Cephalohematoma involves localized bleeding beneath the periosteum, typically over a single bone.
A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurse's best response?
- A. Formula may turn sour after it is opened.'
- B. Bacteria can grow rapidly in warm milk.'
- C. Formula loses some nutritional value once it is opened.'
- D. This makes it easier to keep track of how much the baby is taking.'
Correct Answer: B
Rationale: The correct answer is B because bacteria can grow rapidly in warm milk, increasing the risk of contamination and illness for the baby. Opening a new bottle for each feeding ensures the formula is fresh and safe for consumption. Choice A is incorrect because formula does not necessarily turn sour immediately after opening. Choice C is incorrect because nutritional value does not significantly decrease after opening. Choice D is incorrect as it does not address the health and safety concerns associated with bacteria growth in opened formula.
A mother brings her 4-week-old newborn into the clinic for a well-child check. She reports to the nurse that the newborn developed small white marks on her nose. What are these small white marks commonly called?
- A. Milia
- B. Mongolian spots
- C. Erythema toxicum
- D. Port-wine stain
Correct Answer: A
Rationale: The correct answer is A: Milia. Milia are tiny, white, pearly bumps that commonly appear on a newborn's face, including the nose, due to blocked oil glands. They are harmless and typically disappear on their own.
Explanation:
1. Milia are common in newborns, appearing as small white bumps on the nose and face.
2. They result from blocked oil glands and are not harmful.
3. Mongolian spots are bluish-gray birthmarks usually on the lower back or buttocks.
4. Erythema toxicum presents as red blotches on the skin shortly after birth.
5. Port-wine stain is a vascular birthmark that appears as a pink or red mark on the skin.
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.