Nokea
How should the nurse position a child who is about to undergo a lumbar puncture?
- A. Prone position
- B. Fowler's position
- C. Supine position
- D. Side-lying position
Correct Answer: D
Rationale: The side-lying position with the back curved and knees flexed maximizes spinal flexion, facilitating access to the subarachnoid space for a lumbar puncture.
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A healthy postpartum mother who is breastfeeding her term infant tells the nurse that she has noticed that her roommate is feeding iron-enriched formula to her newborn. The mother asks if she should be giving her baby supplemental iron. Which response by the nurse is correct?
- A. “Your breast milk provides all the iron your baby needs.”
- B. “You,not your baby will need an iron supplement daily.”
- C. “Your pediatrician will prescribe iron drops for your baby.”
- D. “You should feed your baby iron-fortified formula once daily.”
Correct Answer: A
Rationale: Breast milk provides sufficient highly bioavailable iron for term infants making supplementation unnecessary. Maternal iron supplements or formula feeding are not required.
The nurse is caring for the newborn infant. Which initial measures should the nurse take to maintain the newborn’s axillary body temperature between 97.7°F (36.5°C) and 98.9°F (37.2°C)? Select all that apply.
- A. Carefully dry the infant immediately after birth.
- B. Place the infant skin-to-skin with the mother.
- C. Apply leggings to both of the newborn’s legs.
- D. Cover the infant’s head with a stocking cap.
- E. Place the infant in a bassinette close to the wall.
Correct Answer: A,B,D
Rationale: Drying the newborn prevents heat loss through evaporation. Skin-to-skin contact with the mother assists in maintaining body temperature. A stocking cap conserves heat. Leggings are unnecessary and placing the bassinette near a wall causes radiation heat loss.
The nurse meets the frantic father at an ED door. He says he just delivered his wife’s full-term newborn in the car when the temperature outside is only 10°F (—12.2°C). In response to the cold environment,the nurse knows that the infant’s body will immediately begin to produce heat by which mechanism?
- A. Shivering
- B. Metabolizing body fat
- C. Dilating surface blood vessels
- D. Decreasing flexion of the extremities
Correct Answer: B
Rationale: When skin receptors of full-term newborns perceive a drop in environmental temperature the sympathetic nervous system is stimulated. This in turn stimulates metabolism of brown fat thus producing heat that is transferred to the peripheral circulation. Shivering is rarely seen in newborns and it does little to produce heat. Newborns conserve heat by constricting not dilating blood vessels. Decreasing flexion promotes heat loss by exposing more skin surface.
When a 10-year-old child falls from a bicycle and loses a permanent incisor tooth, which advice can the nurse provide to the parents before they take the child to see a dentist?
- A. Submerge the tooth in water in a cup.
- B. Place the tooth under the child's tongue.
- C. Wrap the tooth in a clean cloth.
- D. Clean the tooth with alcohol.
Correct Answer: C
Rationale: Wrapping the tooth in a clean cloth preserves it for potential reimplantation by keeping it clean and protected without compromising its viability.
Crowning is best defined as:
- A. When the greatest diameter of fetal head comes through vulva.
- B. When presenting part reaches the pelvic floor.
- C. When the perineum bulges in front of fetal head.
- D. When fetal head is visible at vulva.
- E. When head is delivered.
Correct Answer: C
Rationale: Crowning occurs when the perineum bulges due to the fetal head’s largest diameter stretching the vaginal opening just before delivery. Other definitions describe different stages.