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How can the nurse assess the successful transition of the respiratory system in the newborn? Select all that apply.
- A. Dry the baby thoroughly.
- B. Suctioning the mouth and nose with a bulb syringe to clear mucus.
- C. Observe the chest and abdomen.
- D. Count the number of respirations per minute.
- E. Observe the color of the mucous membranes.
Correct Answer: B,C,D,E
Rationale: Suctioning, observing chest/abdomen, counting respirations, and checking mucous membrane color assess respiratory function effectively.
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A nurse is assisting in the care of a newborn born 1 hr ago who was delivered at 38 weeks of gestation. Which action should the nurse take first?
- A. The nurse should first report the client's Hemoglobin level to the primary health care.
- B. The nurse should first report the client's Chest x-ray results to the primary health care.
- C. The nurse should first report the client's Glucose level to the primary health care.
Correct Answer: B
Rationale: Chest x-ray results showing radiopaque areas suggest respiratory issues, requiring urgent reporting to guide treatment.
What should be included in teaching for bottle-feeding parents? Select all that apply.
- A. Warm the bottle in the microwave.
- B. Store prepared bottles in the refrigerator.
- C. Discard unused formula in used bottle after 2 hours.
- D. Never prop a bottle.
- E. Formula is available in three forms.
Correct Answer: B,C,D,E
Rationale: Refrigeration, discarding used formula, avoiding propping, and explaining formula forms ensure safe feeding practices.
A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?
- A. Cephalhematoma.
- B. Nevus flammeus.
- C. Caput succedaneum.
- D. Molding.
Correct Answer: A
Rationale: Cephalhematoma is swelling confined by suture lines, distinguishing it from caput succedaneum, which crosses them.
Which statement about fetal circulation is true?
- A. Fetal circulation is no longer effective at birth.
- B. Fetal circulation continues until red blood cells are broken down.
- C. Fetal circulation continues until after the stress of labor.
- D. Fetal circulation continues until adulthood.
Correct Answer: C
Rationale: Fetal circulation, with shunts like the foramen ovale, persists through labor's stress, transitioning to adult circulation after birth.
A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?
- A. The fit of the newborn's clothes.
- B. The number of wet diapers per day.
- C. How often the newborn cries.
- D. The newborn's skin turgor.
Correct Answer: B
Rationale: Wet diapers (6-8 daily) indicate adequate hydration, a reliable measure in newborns.