Nokea
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.
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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.
A home health nurse visits a 2-week-old infant and observes the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. Given these assessment findings, what instruction should the nurse give the parent?
- A. cover the umbilicus with a band-aid
- B. continue to clean the stump with alcohol for 1 week
- C. apply an antibiotic ointment to the stump
- D. give the baby a bath in an infant tub now
Correct Answer: D
Rationale: The correct answer is D: give the baby a bath in an infant tub now. This instruction is appropriate as the umbilical cord has dried and fallen off, indicating that the area is healed. Giving the baby a bath in an infant tub will help keep the area clean and promote healing.
A: Covering the umbilicus with a band-aid is unnecessary and may hinder air circulation, leading to potential infection.
B: Continuing to clean the stump with alcohol for 1 week is unnecessary as the cord has already fallen off and the area is healed.
C: Applying an antibiotic ointment to the stump is not recommended unless there are signs of infection, which are not present in this case.
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.
When assessing a newborn baby
- A. which action should the nurse perform first?
- B. Auscultate the babys heart and lungs.
- C. Don clean gloves before taking the baby.
- D. Record the parents choice of name.
Correct Answer: B
Rationale: The nurse should observe standard precautions when handling a neonate until all blood and amniotic fluid has been removed to avoid possible infection. Then the nurse can take the baby and suction the babys mouth and then the nares if needed. Auscultating the babys heart and lungs will occur later. The parents may not name the baby immediately but even if they have recording the name would not take priority over using standard precautions to prevent the spread of disease.