Nokea
An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:
- A. Hypocalcemia
- B. Birth injury
- C. Hypoglycemia
- D. Seizures
Correct Answer: C
Rationale: Hypoglycemia often presents with tremors, irritability, and poor feeding in newborns. It is common due to the high energy demands and limited glycogen stores.
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The nurse notices that a 6-hour-old newborn patient’s urethral opening is on the dorsal side of the penis. The nurse knows that this is called what?
- A. hypospadias
- B. epispadias
- C. phimosis
- D. unispadias
Correct Answer: B
Rationale: Epispadias is a congenital condition where the urethral opening is located on the dorsal side of the penis.
The labor and delivery nurse understands that some neonates spontaneously take a breath once the head and chest is delivered. Which understanding does the nurse have for the neonate that requires chemical stimuli to breathe?
- A. Oxygen is applied immediately to start respirations.
- B. Carbon dioxide is administered in small doses.
- C. Mild hypoxia and decreased pH stimulates the brain.
- D. Suctioning is used to stimulate breathing efforts.
Correct Answer: C
Rationale: Step 1: Mild hypoxia and decreased pH stimulate the brain to initiate breathing in neonates.
Step 2: This chemical stimuli trigger the respiratory centers in the brainstem.
Step 3: Oxygen administration may not be necessary as the neonate's own respiratory drive is initiated by chemical stimuli.
Step 4: Carbon dioxide administration is not needed as high levels can be harmful.
Step 5: Suctioning is not used to stimulate breathing but to clear airways if necessary.
Summary: Choice C is correct as it aligns with the physiological response of neonates to chemical stimuli for breathing, while the other choices are not relevant or could be potentially harmful.
When teaching umbilical cord care to a new parent, the nurse would include which information?
- A. Apply peroxide to the cord with each diaper change.
- B. Cover the cord with petroleum jelly after bathing.
- C. Keep the cord dry and open to air.
- D. Wash the cord with soap and water each day during a tub bath.
Correct Answer: C
Rationale: Keeping the cord dry and exposed to air promotes healing.
A neonates 5-minute Apgar assessment reveals the following: active motion; pulse
- A. 126 beats/minute; grimace and coughing during suctioning; appearance
- B. good color all over; and respirations slightly irregular with weak cry. What action by the nurse is most appropriate?
- C. Assess oxygen saturation and administer oxygen if needed.
- D. Document the findings in the chart and begin the identification process.
Correct Answer: A
Rationale: The babys 5-minute Apgar score is 8 (motion 2; pulse 2; grimace 2; appearance 1; respirations 1). If a 5-minute Apgar score is less than 9 the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this babys problems are related to either oxygenation or perfusion the nurse should assess the oximetry reading and administer oxygen if needed.
The newborn nursery nurse knows that infant behavior is best assessed by which of the following?
- A. Ease of learning to nurse
- B. Length of sleeping periods
- C. Presence of reflex activity
- D. Response to stimulation
Correct Answer: D
Rationale: Assessing a baby's response to stimulation is a vital part of a behavioral assessment. The other assessments are not really related, although a jittery, overstimulated baby who does not sleep well may need a quieter environment and more gentle handling.