Nokea
Developing a plan to achieve patient outcomes is included in which step of the CJMM?
- A. prioritizing hypotheses
- B. generating solutions
- C. taking action
- D. evaluating outcomes
Correct Answer: B
Rationale: Generating solutions involves creating strategies to address identified problems, which includes developing plans to achieve desired patient outcomes.
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The mother-baby nurse is providing care to a patient and her newborn 2 hours after delivery. On review of the newborn's chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother's chart?
- A. Race: non-White
- B. A longer than usual labor
- C. Administration of an epidural
- D. Delivery by cesarean birth
Correct Answer: B
Rationale: The correct answer is B: A longer than usual labor. Caput succedaneum is swelling of the baby's scalp due to pressure during labor. This indicates a longer labor duration.
A: Race is not a factor in the development of caput succedaneum.
C: Administration of an epidural does not directly cause caput succedaneum.
D: Delivery by cesarean birth is not associated with caput succedaneum.
Which step is most appropriate following delivery of a healthy newborn?
- A. Assess the newborn's temperature rectally following delivery.
- B. Place the newborn skin to skin in the mother's arms after the baby is dry.
- C. Clothe the baby and place the newborn under the radiant warmer until the temperature is stable.
- D. Wrap the baby in warm blankets; apply a cap to the bed and place open crib near the window.
Correct Answer: B
Rationale: Step 1: Placing the newborn skin to skin in the mother's arms helps with bonding, regulates the baby's temperature, and promotes breastfeeding initiation.
Step 2: Skin-to-skin contact supports the baby in transitioning to the outside world comfortably.
Step 3: Keeping the baby dry and close to the mother promotes a sense of security and comfort.
Step 4: This approach aligns with evidence-based practices for newborn care.
Summary:
A: Assessing the newborn's temperature rectally is not the immediate priority after delivery.
C: Placing the baby under the radiant warmer may disrupt bonding and delay skin-to-skin contact.
D: Wrapping the baby in warm blankets without skin-to-skin contact may lead to heat loss and hinder maternal-infant bonding.
The newborn nursery nurse walks into the mother's room and notices the patient next to the window. What is the nurse's next course of action?
- A. Ask the mom to hold the infant using skin-to-skin contact.
- B. Nothing; infants are encouraged to be near the windows for sun exposure.
- C. Place the infant near the door on the other side of the room.
- D. Position the baby on the baby scale to obtain a weight.
Correct Answer: A
Rationale: The correct answer is A: Ask the mom to hold the infant using skin-to-skin contact. This is because skin-to-skin contact between the mother and newborn is important for bonding, regulating the baby's temperature, promoting breastfeeding, and comforting the baby. It also helps establish trust and promote attachment.
Choice B is incorrect because newborns should not be exposed to direct sunlight for long periods due to the risk of sunburn and overheating.
Choice C is incorrect because there is no specific benefit to placing the infant near the door, and it does not address the importance of skin-to-skin contact.
Choice D is incorrect because obtaining the baby's weight is not the immediate priority when entering the room, especially when the opportunity for skin-to-skin contact is present.
The nursery nurse notes the presence of diffuse edema on a newborn babys head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. What action by the nurse is best?
- A. Document the findings in the infants chart.
- B. Measure head circumference every 12 hours.
- C. Prepare to administer IV osmotic diuretics.
- D. Transfer the baby to the NICU for monitoring.
Correct Answer: A
Rationale: Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life. It often is the result of a traumatic or difficult birth. The nurse should document the findings. No other action is needed.
What is the term for a common and harmless skin condition on an infant’s scalp that presents as yellow scaly patches with a red rash?
- A. erythema toxicum
- B. eczema
- C. a skin allergy
- D. cradle cap
Correct Answer: D
Rationale: Cradle cap is a common, harmless condition characterized by yellow scaly patches on the scalp.