Nokea
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: The correct answer is . Decreased temperature (B) can indicate hypoglycemia, sepsis, or hypothermia. Lethargy (C) can be a sign of hypoglycemia, sepsis, or other serious conditions. Poor feeding (D) is common in hypoglycemia, sepsis, and other illnesses. Respiratory distress (E) is a red flag for sepsis. Yellow sclera and oral mucosa (F) suggest hyperbilirubinemia. Ecchymotic caput Succedaneum (A) is not typically associated with these conditions.
You may also like to solve these questions
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours may indicate pathological conditions such as hemolytic disease or liver dysfunction. It requires immediate evaluation and treatment. Acrocyanosis (A) is a common finding in newborns due to immature circulation. Transient strabismus (B) is often seen in newborns and typically resolves on its own. Caput succedaneum (D) is swelling on the newborn's scalp from pressure during birth, which is a normal finding.
A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I will position my baby at a 45-degree angle in the car seat.
- B. I can place my baby in the front seat with the airbag turned off.
- C. I can turn my baby's car seat around when she weighs 15 pounds.
- D. I will place my baby in a forward-facing car seat in my back seat.
Correct Answer: A
Rationale: Correct Answer: A. "I will position my baby at a 45-degree angle in the car seat."
Rationale: Placing the newborn at a 45-degree angle in the car seat supports the baby's airway and prevents slumping, ensuring proper breathing and safety. This position helps reduce the risk of suffocation and allows the baby's head to be supported. It is recommended by pediatric experts as the safest way for a newborn to travel in a car seat.
Summary of other choices:
B: Placing a baby in the front seat with the airbag turned off is not safe, as the back seat is the safest place for children under 13 years old.
C: Turning the baby's car seat around at 15 pounds is incorrect as rear-facing is recommended until at least 2 years of age.
D: Using a forward-facing car seat for a newborn is unsafe, as infants should be in a rear-facing seat until they outgrow the height or weight limit.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks gestation with a positive contraction stress test, the client may be at risk for uteroplacental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, tone, breathing, amniotic fluid volume, and fetal heart rate reactivity. This test helps determine if the fetus is getting enough oxygen and nutrients. Preparing the client for a BPP is crucial in monitoring the fetal status and making decisions regarding further management.
Incorrect choices:
A: Percutaneous umbilical blood sampling is an invasive procedure used to evaluate fetal blood gases and acid-base status, typically performed when there are concerns about fetal well-being like severe growth restriction or Rh incompatibility.
B: Amnioinfusion is the infusion of fluid into the amniotic cavity and is used to correct oligohydramnios (low amniotic fluid volume).
D: Chorionic villus
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Pain assessment in newborns can be challenging due to their limited ability to communicate. Chin quivering is a nonverbal sign of pain in newborns. It indicates stress and discomfort. Decreased heart rate, pinpoint pupils, and slowed respirations are not reliable indicators of pain in newborns and may be attributed to other factors. Therefore, the nurse should identify chin quivering as a significant sign of pain in this scenario.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lie in a supine position throughout the test.
- C. You should not eat or drink for hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: The correct answer is D: You should press the handheld button when you feel your baby move. In a nonstress test, the client is required to press a handheld button whenever they feel the baby move. This action helps to correlate fetal movements with changes in the fetal heart rate, allowing healthcare providers to assess the baby's well-being. This active participation from the client ensures accurate monitoring of the baby's condition. The other choices are incorrect because: A: The duration of a nonstress test can vary but typically takes around 20-40 minutes. B: Lying in a supine position is not recommended during pregnancy as it can decrease blood flow to the baby. C: It is important for the client to have a light meal before the test to ensure the baby is active during monitoring.