Nokea
During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. How does the nurse document this finding?
- A. nevus vasculosus
- B. Mongolian spots
- C. nevus flammeus
- D. telangiectatic nevi
Correct Answer: D
Rationale: The correct answer is D: telangiectatic nevi. These are also known as "stork bites" or "angel kisses." The rationale for this choice is that telangiectatic nevi are pale pink spots commonly found on the nape of the neck in newborns, which typically fade over time.
A: Nevus vasculosus is a different type of birthmark characterized by a red or purple color due to an overgrowth of blood vessels.
B: Mongolian spots are bluish-gray birthmarks usually found on the lower back or buttocks.
C: Nevus flammeus, also known as a port-wine stain, presents as a flat, pink, or red mark on the skin.
In summary, the correct answer, telangiectatic nevi, is the most appropriate choice based on the description of the finding on the newborn's nape of the neck, while the other options describe different types of birthmarks with distinct characteristics.
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An infant has just been admitted to the newborn nursery after an uncomplicated delivery. Upon assessment, the nurse notes poor muscle tone and a temperature of 96°F axillary. What is the next course of action?
- A. Obtain a blood glucose reading
- B. Prepare for resuscitation needs
- C. Call for a transfer to the neonatal intensive care unit
- D. Place warm blankets around the newborn in the open crib
Correct Answer: A
Rationale: The correct next course of action is to obtain a blood glucose reading (Choice A). Poor muscle tone and low temperature in a newborn can be indicative of hypoglycemia, which is a common issue in infants. By checking the blood glucose level, the healthcare provider can determine if hypoglycemia is the cause of the symptoms. This action allows for prompt intervention if needed. Choices B, C, and D are incorrect as they do not address the potential underlying issue of hypoglycemia. Resuscitation needs (Choice B) should only be considered if the infant's condition deteriorates. Calling for a transfer to the neonatal intensive care unit (Choice C) may not be necessary if the issue can be managed in the nursery. Placing warm blankets (Choice D) may help with temperature regulation but does not address the root cause of the symptoms.
Which infant is not at risk for heat loss?
- A. Infant born at 38 weeks gestational age on a baby scale
- B. Preterm infant lying extended in the warmer
- C. Term infant who is lying in an open crib next to the door
- D. Infant born at 41 weeks swaddled in the open crib of the nursery
Correct Answer: D
Rationale: The correct answer is D because swaddling helps maintain the infant's body temperature by preventing heat loss. Swaddling creates a cocoon-like environment, reducing exposure to external factors. Choice A is incorrect because a baby scale does not provide warmth. Choice B is incorrect as the preterm infant is in an extended position, which increases heat loss. Choice C is incorrect as the term infant lying next to the door may experience drafts and heat loss.
The nurse enters the room of a patient who just gave birth 2 days ago to a healthy newborn. The nurse asks her what her newborn's name is and she shrugs and says, 'I haven't thought about a name yet.' What priority is the nurse most concerned about with this patient?
- A. The patient has not transitioned from the fourth stage of labor.
- B. Parent-to-newborn attachment may be a concern.
- C. The mother may be contemplating suicide.
- D. Different cultural practices.
Correct Answer: B
Rationale: The correct answer is B: Parent-to-newborn attachment may be a concern. The nurse is most concerned about the lack of bonding or attachment between the mother and her newborn, as indicated by the mother not having thought about a name yet. This lack of interest or engagement with the newborn could potentially impact the mother's ability to form a healthy attachment, which is crucial for the newborn's well-being. The nurse should prioritize assessing and supporting the mother in developing a bond with her baby.
Choices A, C, and D are incorrect:
A: The patient not naming the newborn does not indicate she has not transitioned from the fourth stage of labor.
C: There is no evidence to suggest that the mother may be contemplating suicide based solely on her not naming the newborn.
D: Different cultural practices do not seem to be the primary concern in this scenario compared to the potential lack of parent-to-newborn attachment.
The nurse is completing an initial assessment of the newborn. The newborn’s ears appear to be parallel to the outer and inner canthus of the eye. How does the nurse document the ear placement?
- A. low set
- B. high set
- C. a normal position
- D. facial paralysis
Correct Answer: C
Rationale: Ears positioned parallel to the outer and inner canthus are considered normal.
The nurse is teaching a student nurse about some of the differences between a term and preterm infant. Which statement is most accurate?
- A. Infants born at 32 weeks gestational age have sufficient alveolar stability to maintain adequate lung expansion.
- B. Surfactant may need to be given to the infant born less than 34 to 36 weeks of age to assist with alveolar stability.
- C. Women with gestational diabetes have larger babies; therefore, there are fewer issues with lung maturity when born preterm.
- D. Mothers carrying multiples fetuses will increase the surfactant production naturally in utero.
Correct Answer: B
Rationale: The correct answer is B because infants born before 34 to 36 weeks gestational age may not have fully developed surfactant production, which is crucial for alveolar stability and lung expansion. Surfactant reduces surface tension in the alveoli, preventing their collapse. Without sufficient surfactant, preterm infants are at risk of respiratory distress syndrome.
Choice A is incorrect because infants born at 32 weeks may still have underdeveloped alveoli and insufficient surfactant production, leading to potential lung expansion issues.
Choice C is incorrect because the presence of gestational diabetes does not guarantee sufficient lung maturity in preterm infants. Lung maturity is more closely related to gestational age and surfactant production.
Choice D is incorrect because while carrying multiple fetuses can slightly increase surfactant production, it may not be sufficient for preterm infants born before 34 to 36 weeks, necessitating the need for exogenous surfactant administration.