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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: C
Rationale: Nevus flammeus, also known as salmon patches, are common vascular markings often seen on the nape of the neck.
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When thinking about scoring an Apgar assessment, the nurse knows that grimace is an assessment of what in a newborn?
- A. Grimace is an assessment of a newborn's response to taking their first breath.
- B. Grimace is an assessment of the flexion of hips and legs in the newborn.
- C. Grimace is an assessment of the response to seeing their birthing person's face.
- D. Grimace is an assessment of the response to stimulation from the nurse.
Correct Answer: D
Rationale: The correct answer is D because the grimace in an Apgar assessment refers to the newborn's response to stimulation, such as a gentle pinch or suctioning. This response indicates the baby's reflexes and neurological function, which are important indicators of overall health. Choices A and C are incorrect because the grimace is not specifically related to breathing or visual stimuli. Choice B is incorrect because it refers to a different aspect of the assessment (muscle tone).
The perinatal nurse notes that a newborn does not seem to have an opening inside the anal ring. Which action by the nurse takes priority?
- A. Ask the mother how well the infant is eating.
- B. Assess the abdomen and notify the physician.
- C. Facilitate laboratory studies for kidney function.
- D. Reassure the parents that this is a normal deviation.
Correct Answer: B
Rationale: This infant may have an imperforate anus, a condition that is an emergency, as the infant cannot pass stool. The nurse should quickly assess the baby's abdomen for distention and firmness and notify the physician or health-care provider. The other actions are not warranted.
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: Once healed, the area can be submerged in water during baths.
Edward, a newborn delivered at 41 weeks' gestation, weighs 10 lb 4 oz. Vaginal delivery for this G1P1 mother was assisted with forceps. The nurse is completing her assessment and notes a sharply demarcated swelling over the parietal bones. The occipital and frontal skull bones are not affected. The neck does not appear edematous and is soft to the touch with full mobility. The infant is awake and active and has been breast-feeding well. What is the most probable cause of the swelling?
- A. cephalohematoma
- B. subgaleal hemorrhage
- C. caput succedaneum
- D. skull fracture
Correct Answer: A
Rationale: Cephalohematoma involves localized bleeding beneath the periosteum, typically over a single bone.
The most effective time to initiate breast-feeding is in which stage of reactivity for the neonate?
- A. period of decreased reactivity
- B. first period of reactivity
- C. second period of reactivity
- D. after the end of the second period of reactivity
Correct Answer: B
Rationale: The correct answer is B: first period of reactivity. During this stage, the infant is alert and eager to suckle, making it an optimal time to initiate breastfeeding. The infant's sucking reflex is strong, and they are more likely to latch on successfully. The other choices are incorrect because during the period of decreased reactivity (A), the infant is often drowsy and less interested in feeding. The second period of reactivity (C) may involve increased activity and may not be the best time to introduce breastfeeding. After the end of the second period of reactivity (D), the infant may be more settled and not as ready to breastfeed as during the first period of reactivity.