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An infant with a congenital cardiac disorder is receiving postsurgical palliation and nearing time for discharge. What findings would be indicators that the infant is ready for discharge?
- A. The infant is medically ready, has had all routine discharge screenings, and is up to date on their vaccinations.
- B. The home caregiver has not been able to come to the hospital and has not received either CPR or needed NG tube training.
- C. The respiratory therapist has done a home evaluation, which showed the home environment was appropriate, but the DME has not shipped the ventilator or oxygen delivery equipment.
- D. The infant is escalating on oxygen requirements and unable to maintain their temperature between 36.6° C and 38° C.
Correct Answer: A
Rationale: Medical readiness, completed screenings, and up-to-date vaccinations indicate discharge readiness.
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How can the nurse caring for a patient with a neonatal loss practice self-care?
- A. Refrain from discussing her feelings at work.
- B. Understand that depression is normal after neonatal loss.
- C. Take off work for a week.
- D. Debrief with manager and colleagues.
Correct Answer: D
Rationale: Debriefing with colleagues and managers allows for emotional processing and support, which is crucial after a neonatal loss. Suppressing emotions or taking prolonged leave may hinder recovery and professional functioning.
Which technique should the nurse recommend to the postpartum patient in order to prevent nipple trauma?
- A. Assess the nipples before each feeding.
- B. Limit the feeding time to less than 5 minutes.
- C. Wash the nipples daily with mild soap and water.
- D. Position the infant so the nipple is far back in the mouth.
Correct Answer: D
Rationale: The correct answer is D: Position the infant so the nipple is far back in the mouth. This technique helps prevent nipple trauma by ensuring that the baby latches onto the breast correctly, with a deep latch that prevents excessive pressure and friction on the nipple. By positioning the nipple far back in the baby's mouth, the baby can effectively suckle and draw milk without causing damage to the nipple.
Choice A is incorrect because simply assessing the nipples before each feeding does not actively prevent trauma. Choice B is incorrect as limiting feeding time to less than 5 minutes can lead to inadequate milk transfer and potential nipple trauma due to improper latch. Choice C is incorrect as washing the nipples daily with soap and water can actually strip the skin of natural oils and increase the risk of dryness and cracking, leading to trauma.
In preparing a family for discharge from the perinatal unit, which method of nail care does the nurse teach as the preferred method?
- A. Cutting the nails with sharp scissors
- B. Filing the nails with a fine emery board
- C. Letting the nails break off naturally
- D. Wrapping the infant's hands in mittens
Correct Answer: B
Rationale: Several options exist for nail care to keep the infant from scratching her face. The nails can be cut, but there is a risk of damaging the delicate skin around the nail. This is best done while the baby sleeps. Letting the nails break off is not a good option, as the child may injure herself before they break. Covering the hands with mittens or a tee shirt is a possible option, but does not allow the child to suck on the fingers for self-soothing. The best option is to file the nails gently with a fine-grained emery board.
Which assessment finding of a newborn requires prompt action by the nurse?
- A. Respiratory rate of 50 breaths per minute
- B. Cyanosis of the extremities
- C. Pause in breathing lasting 20 seconds
- D. Pause in breathing for 15 seconds followed by rapid respirations
Correct Answer: C
Rationale: The correct answer is C: Pause in breathing lasting 20 seconds. This finding indicates a potential apnea episode in the newborn, which requires immediate attention to prevent further complications like hypoxia. The pause in breathing lasting 20 seconds exceeds the normal range for apnea in newborns, typically defined as a pause lasting more than 15 seconds. Prompt action is necessary to assess and address the underlying cause of the apnea episode.
Choice A (Respiratory rate of 50 breaths per minute) is within the normal range for newborns (30-60 breaths per minute) and does not require immediate action. Choice B (Cyanosis of the extremities) may indicate poor circulation but is not as urgent as a prolonged pause in breathing. Choice D (Pause in breathing for 15 seconds followed by rapid respirations) is incorrect as it does not meet the criteria for apnea in newborns and does not require immediate action.
At birth, a newborn weighed 6 pounds, 12 ounces. Three days later, the newborn weighs 5 pounds, 10 ounces. What conclusion should the nurse draw regarding this newborn’s weight?
- A. This weight loss is within normal limits.
- B. This weight gain is within normal limits.
- C. This weight loss is excessive.
- D. This weight gain is excessive.
Correct Answer: A
Rationale: A weight loss of up to 10% in the first few days is considered normal.